Healthcare Provider Details

I. General information

NPI: 1114654209
Provider Name (Legal Business Name): AIMIEL TRISHA WAREZA CASILLAN GC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/08/2022
Last Update Date: 08/08/2022
Certification Date: 08/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9300 VALLEY CHILDRENS PL
MADERA CA
93636-8761
US

IV. Provider business mailing address

24135 MEADOWBROOK LN
VALENCIA CA
91354-1881
US

V. Phone/Fax

Practice location:
  • Phone: 559-353-3000
  • Fax:
Mailing address:
  • Phone: 661-430-3462
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code170300000X
TaxonomyGenetic Counselor (M.S.)
License NumberGC001608
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: