Provider Demographics
NPI:1255059671
Name:MANCILLA, JUAN ANTONIO JR
Entity type:Individual
Prefix:MR
First Name:JUAN
Middle Name:ANTONIO
Last Name:MANCILLA
Suffix:JR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1093 HOBEN RD
Mailing Address - Street 2:
Mailing Address - City:NOCONA
Mailing Address - State:TX
Mailing Address - Zip Code:76255-6561
Mailing Address - Country:US
Mailing Address - Phone:940-841-0159
Mailing Address - Fax:
Practice Address - Street 1:3601 4TH ST
Practice Address - Street 2:
Practice Address - City:LUBBOCK
Practice Address - State:TX
Practice Address - Zip Code:79430-0002
Practice Address - Country:US
Practice Address - Phone:806-743-1000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer