Healthcare Provider Details

I. General information

NPI: 1528878287
Provider Name (Legal Business Name): JOSE DE JESUS VILLA RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/13/2025
Last Update Date: 04/07/2025
Certification Date: 04/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1777 BUCKMAN SPRINGS RD
CAMPO CA
91906-2022
US

IV. Provider business mailing address

1777 BUCKMAN SPRINGS RD
CAMPO CA
91906-2022
US

V. Phone/Fax

Practice location:
  • Phone: 619-478-5696
  • Fax: 619-478-2404
Mailing address:
  • Phone: 619-478-5696
  • Fax: 619-478-2404

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1498920323
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-USVMKC
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: