Basic Information
| Provider Information | |||||||||
| NPI: | 1730221482 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTILLAN | ||||||||
| FirstName: | MAYRA | ||||||||
| MiddleName: | VERONICA | ||||||||
| NamePrefix: | MRS. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11839 KIRKSTON PL | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923925700 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6266018025 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 2085 RUSTIN AVE # 5 | ||||||||
| Address2: | |||||||||
| City: | RIVERSIDE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 925072498 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9515092400 | ||||||||
| FaxNumber: | 9515092404 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 08/26/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 08/26/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225400000X | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner | 171M00000X | Y | Other Service Providers | Case Manager/Care Coordinator |
No ID Information.