Healthcare Provider Details

I. General information

NPI: 1295281129
Provider Name (Legal Business Name): ALEXANDER CANTILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/31/2016
Last Update Date: 08/28/2019
Certification Date:
Deactivation Date: 08/06/2019
Reactivation Date: 08/22/2019

III. Provider practice location address

26081 MOCINE AVE
HAYWARD CA
94544-2923
US

IV. Provider business mailing address

26081 MOCINE AVE
HAYWARD CA
94544-2923
US

V. Phone/Fax

Practice location:
  • Phone: 510-881-5921
  • Fax: 510-881-5925
Mailing address:
  • Phone: 510-881-5921
  • Fax: 510-881-5925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: