Healthcare Provider Details

I. General information

NPI: 1730221482
Provider Name (Legal Business Name): MRS. MAYRA VERONICA SANTILLAN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 08/26/2022
Certification Date: 08/26/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE # 5
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

11839 KIRKSTON PL
VICTORVILLE CA
92392-5700
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2400
  • Fax: 951-509-2404
Mailing address:
  • Phone: 626-601-8025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: