Healthcare Provider Details

I. General information

NPI: 1598130825
Provider Name (Legal Business Name): DEXTER YBIOSA TILLO RRT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2015
Last Update Date: 12/11/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3350 LA JOLLA VILLAGE DR
SAN DIEGO CA
92161-0002
US

IV. Provider business mailing address

14133 CAMINATA AMADOR
SAN DIEGO CA
92129-2065
US

V. Phone/Fax

Practice location:
  • Phone: 858-213-4713
  • Fax:
Mailing address:
  • Phone: 858-213-4713
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number37169
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: