Healthcare Provider Details

I. General information

NPI: 1124566187
Provider Name (Legal Business Name): JORGE ALBERTO VILLALTA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/09/2017
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

78900 AVENUE 47 STE 105
LA QUINTA CA
92253-2070
US

IV. Provider business mailing address

78900 AVENUE 47 STE 105
LA QUINTA CA
92253-2070
US

V. Phone/Fax

Practice location:
  • Phone: 760-625-0951
  • Fax: 760-564-5049
Mailing address:
  • Phone: 760-625-0951
  • Fax: 760-564-5049

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: