Provider Demographics
NPI:1316786973
Name:MANNIL, EJON LEE
Entity type:Individual
Prefix:
First Name:EJON
Middle Name:LEE
Last Name:MANNIL
Suffix:
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 1:20970 RAMBLING RD.
Mailing Address - Street 2:
Mailing Address - City:APPLE VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:92308
Mailing Address - Country:US
Mailing Address - Phone:951-318-4560
Mailing Address - Fax:
Practice Address - Street 1:1000 S. FREMONT AVE.
Practice Address - Street 2:UNIT 7, BLDG. A10, STE. N10100, RM 11150
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91803
Practice Address - Country:US
Practice Address - Phone:626-457-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-23
Last Update Date:2024-05-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program