Basic Information
| Provider Information | |||||||||
| NPI: | 1912582289 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MANCILLA | ||||||||
| FirstName: | JOSE | ||||||||
| MiddleName: | LUIS | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 750 N COMMONS DR STE 200 | ||||||||
| Address2: | |||||||||
| City: | AURORA | ||||||||
| State: | IL | ||||||||
| PostalCode: | 605047940 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6303035380 | ||||||||
| FaxNumber: | 6303035385 | ||||||||
| Practice Location | |||||||||
| Address1: | 30250 RANCHO VIEJO RD STE A | ||||||||
| Address2: | |||||||||
| City: | SAN JUAN CAPISTRANO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926751555 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9494890668 | ||||||||
| FaxNumber: | 9494891475 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/17/2021 | ||||||||
| LastUpdateDate: | 05/05/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 05/05/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 237700000X | 7903 | CA | Y | Speech, Language and Hearing Service Providers | Hearing Instrument Specialist |
ID Information
| ID | Type | State | Issuer | Description | 7903 | 01 | CA | HEARING INSTRUMENT SPECIALIST | OTHER |