Healthcare Provider Details

I. General information

NPI: 1821175522
Provider Name (Legal Business Name): MR. MICHAEL J. VILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1297 W HOBSONWAY
BLYTHE CA
92225-1423
US

IV. Provider business mailing address

1297 W HOBSONWAY
BLYTHE CA
92225-1423
US

V. Phone/Fax

Practice location:
  • Phone: 760-921-5000
  • Fax: 760-921-5010
Mailing address:
  • Phone: 760-921-5000
  • Fax: 760-921-5010

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberA-4977
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: