Provider Demographics
NPI:1750169017
Name:R ALEX MANCILLA OD PC
Entity type:Organization
Organization Name:R ALEX MANCILLA OD PC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/DOCTOR
Authorized Official - Prefix:
Authorized Official - First Name:RAUL
Authorized Official - Middle Name:A
Authorized Official - Last Name:MANCILLA
Authorized Official - Suffix:
Authorized Official - Credentials:OD
Authorized Official - Phone:619-370-7315
Mailing Address - Street 1:435 W ATEN RD STE 3
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9819
Mailing Address - Country:US
Mailing Address - Phone:619-370-7315
Mailing Address - Fax:
Practice Address - Street 1:435 W ATEN RD STE 3
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-9819
Practice Address - Country:US
Practice Address - Phone:619-370-7315
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-09-18
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes152W00000XEye and Vision Services ProvidersOptometristGroup - Single Specialty