Healthcare Provider Details

I. General information

NPI: 1366914319
Provider Name (Legal Business Name): JORDAN MAURO MAITILASSO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/31/2018
Last Update Date: 08/10/2020
Certification Date: 08/10/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10159 MISSION GORGE RD STE C
SANTEE CA
92071-3857
US

IV. Provider business mailing address

625 VAN HOUTEN AVE APT J
EL CAJON CA
92020-5184
US

V. Phone/Fax

Practice location:
  • Phone: 619-579-0947
  • Fax: 619-588-6282
Mailing address:
  • Phone: 619-206-7131
  • 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 StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: