Provider Demographics
NPI:1023550720
Name:MANCILLAS, NATHANIEL (DPT)
Entity type:Individual
Prefix:
First Name:NATHANIEL
Middle Name:
Last Name:MANCILLAS
Suffix:
Gender:M
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:625 ENTERPRISE DR
Mailing Address - Street 2:
Mailing Address - City:OAK BROOK
Mailing Address - State:IL
Mailing Address - Zip Code:60523-8813
Mailing Address - Country:US
Mailing Address - Phone:630-575-6250
Mailing Address - Fax:630-575-7450
Practice Address - Street 1:1747 E 95TH ST
Practice Address - Street 2:
Practice Address - City:CHICAGO
Practice Address - State:IL
Practice Address - Zip Code:60617-4708
Practice Address - Country:US
Practice Address - Phone:773-375-8711
Practice Address - Fax:773-375-8703
Is Sole Proprietor?:No
Enumeration Date:2016-11-11
Last Update Date:2016-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL070022749225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist