Basic Information
| Provider Information | |||||||||
| NPI: | 1114298957 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IDYLLE | ||||||||
| FirstName: | LILIANE | ||||||||
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| Credential: | D.O. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 12900 PARK PLAZA DR STE 150 | ||||||||
| Address2: | |||||||||
| City: | CERRITOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 907039329 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5629774639 | ||||||||
| FaxNumber: | 5627414479 | ||||||||
| Practice Location | |||||||||
| Address1: | 2444 W BEVERLY BLVD | ||||||||
| Address2: | |||||||||
| City: | MONTEBELLO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 906402306 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5623338288 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/25/2012 | ||||||||
| LastUpdateDate: | 08/21/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 207R00000X | 12060 | CA | Y | Allopathic & Osteopathic Physicians | Internal Medicine |
ID Information
| ID | Type | State | Issuer | Description | 113319 | 01 | CA | SID #113319 | OTHER |