Healthcare Provider Details

I. General information

NPI: 1003798216
Provider Name (Legal Business Name): ANSELM-MICHAEL PADILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2025
Last Update Date: 07/21/2025
Certification Date: 07/21/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3950 REYNOLDS RD
RIVERSIDE CA
92503-3517
US

IV. Provider business mailing address

12669 DOGWOOD WAY
MORENO VALLEY CA
92555-2249
US

V. Phone/Fax

Practice location:
  • Phone: 951-358-4466
  • Fax:
Mailing address:
  • Phone: 951-855-9817
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
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: