Healthcare Provider Details

I. General information

NPI: 1881372845
Provider Name (Legal Business Name): JIMI VILLA RADT I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2023
Last Update Date: 08/16/2023
Certification Date: 08/16/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1207 E FRUIT ST
SANTA ANA CA
92701-4296
US

IV. Provider business mailing address

2542 E 218TH PL
CARSON CA
90810-1703
US

V. Phone/Fax

Practice location:
  • Phone: 714-953-9373
  • Fax: 714-953-7573
Mailing address:
  • Phone: 310-924-8226
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1509010523
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: