Basic Information
Provider Information | |||||||||
NPI: | 1285360354 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TRUJILLO | ||||||||
FirstName: | SELENA | ||||||||
MiddleName: | D | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25791 27TH ST | ||||||||
Address2: |   | ||||||||
City: | SAN BERNARDINO | ||||||||
State: | CA | ||||||||
PostalCode: | 924043435 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9093529917 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 10604 N TRADEMARK PKWY | ||||||||
Address2: |   | ||||||||
City: | RANCHO CUCAMONGA | ||||||||
State: | CA | ||||||||
PostalCode: | 917305938 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 9094842848 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 07/29/2022 | ||||||||
LastUpdateDate: | 07/29/2022 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 07/29/2022 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X |   |   | Y |   |   |   |   |
No ID Information.