Basic Information
| Provider Information | |||||||||
| NPI: | 1881080604 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | SANTILLAN | ||||||||
| FirstName: | MANUEL | ||||||||
| MiddleName: | URIEL | ||||||||
| NamePrefix: | MR. | ||||||||
| NameSuffix: | JR. | ||||||||
| Credential: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1237 JOHNSON AVE | ||||||||
| Address2: | |||||||||
| City: | MARYSVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 959016205 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8313200521 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 1133 COLOMA WAY STE C | ||||||||
| Address2: | |||||||||
| City: | ROSEVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956614480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9167746647 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/08/2015 | ||||||||
| LastUpdateDate: | 01/22/2021 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/22/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C056610518 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
No ID Information.