Individual
JORGE MANTILLA
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
Man
Credential
SA-C
Contact information
Practice address
5540 N KIMBALL AVE APT 3E, CHICAGO, IL 60625-4674
(312) 983-0540
Mailing address
5540 N KIMBALL AVE APT 3E, CHICAGO, IL 60625-4674
(312) 983-0540
Taxonomy
Speciality
Code
Description
License number
State
246ZC0007X
Surgical Assistant
19-180
TX
363AS0400X
Surgical Physician Assistant
Primary
238.000655
IL
Other
Enumeration date
04/18/2019
Last updated
02/11/2020
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