Basic Information
| Provider Information | |||||||||
| NPI: | 1255099115 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASILLAS FUENTES | ||||||||
| FirstName: | ROCIO | ||||||||
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| Mailing Information | |||||||||
| Address1: | 75100 MEDITERRANEAN | ||||||||
| Address2: | |||||||||
| City: | PALM DESERT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922119069 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 75100 MEDITERRANEAN | ||||||||
| Address2: | |||||||||
| City: | PALM DESERT | ||||||||
| State: | CA | ||||||||
| PostalCode: | 922119069 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7608370033 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/07/2021 | ||||||||
| LastUpdateDate: | 12/07/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 12/05/2021 | ||||||||
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.