Provider Demographics
NPI:1912582289
Name:MANCILLA, JOSE LUIS JR
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
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 1:750 N COMMONS DR STE 200
Mailing Address - Street 2:
Mailing Address - City:AURORA
Mailing Address - State:IL
Mailing Address - Zip Code:60504-7940
Mailing Address - Country:US
Mailing Address - Phone:630-303-5380
Mailing Address - Fax:630-303-5385
Practice Address - Street 1:30250 RANCHO VIEJO RD STE A
Practice Address - Street 2:
Practice Address - City:SAN JUAN CAPISTRANO
Practice Address - State:CA
Practice Address - Zip Code:92675-1555
Practice Address - Country:US
Practice Address - Phone:949-489-0668
Practice Address - Fax:949-489-1475
Is Sole Proprietor?:No
Enumeration Date:2021-03-17
Last Update Date:2021-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA7903237700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes237700000XSpeech, Language and Hearing Service ProvidersHearing Instrument Specialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7903OtherHEARING INSTRUMENT SPECIALIST