Basic Information
| Provider Information | |||||||||
| NPI: | 1275031551 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MAYORDOMO | ||||||||
| FirstName: | HYACILLE | ||||||||
| MiddleName: | KAY RIVERA | ||||||||
| NamePrefix: | |||||||||
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| Credential: | PT, DPT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | RIVERA MAYORDOMO | ||||||||
| OtherFirstName: | KAY | ||||||||
| OtherMiddleName: | KAY | ||||||||
| OtherNamePrefix: | |||||||||
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| OtherCredential: | PT, DPT | ||||||||
| OtherLastNameType: | 5 | ||||||||
| Mailing Information | |||||||||
| Address1: | 325 DISTEL CIR | ||||||||
| Address2: | |||||||||
| City: | LOS ALTOS | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940221408 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | |||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 582 S SUNNYVALE AVE | ||||||||
| Address2: | |||||||||
| City: | SUNNYVALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 940866125 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4085233060 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/01/2018 | ||||||||
| LastUpdateDate: | 02/18/2020 | ||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
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| AuthorizedOfficialMiddleName: | |||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 02/18/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 294378 | CA | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.