Basic Information
| Provider Information | |||||||||
| NPI: | 1134785942 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | VILLACORTA | ||||||||
| FirstName: | SANDRA | ||||||||
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| Credential: | RBT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1730 E HOLLY AVE | ||||||||
| Address2: | |||||||||
| City: | EL SEGUNDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902454404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444677763 | ||||||||
| FaxNumber: | 8447600312 | ||||||||
| Practice Location | |||||||||
| Address1: | 1730 E HOLLY AVE | ||||||||
| Address2: | |||||||||
| City: | EL SEGUNDO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 902454404 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8444677763 | ||||||||
| FaxNumber: | 8447600312 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 05/16/2019 | ||||||||
| LastUpdateDate: | 05/16/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 247200000X | N | Technologists, Technicians & Other Technical Service Providers | Technician, Other | 106S00000X | Y |
No ID Information.