Healthcare Provider Details

I. General information

NPI: 1003733510
Provider Name (Legal Business Name): MR. SAMUEL LISAMA VILLAPANDO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/04/2026
Last Update Date: 07/04/2026
Certification Date: 07/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10850 ARROW RTE
RANCHO CUCAMONGA CA
91730-4833
US

IV. Provider business mailing address

45571 BASSWOOD CT
TEMECULA CA
92592-2861
US

V. Phone/Fax

Practice location:
  • Phone: 833-574-2273
  • Fax:
Mailing address:
  • Phone: 951-760-0717
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number53970
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: