Healthcare Provider Details

I. General information

NPI: 1174209795
Provider Name (Legal Business Name): CYNTHIA CASILLAS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/27/2023
Last Update Date: 06/27/2023
Certification Date: 06/27/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

284 PENNSYLVANIA DR STE 1
WATSONVILLE CA
95076-3768
US

IV. Provider business mailing address

284 PENNSYLVANIA DR STE 1
WATSONVILLE CA
95076-3768
US

V. Phone/Fax

Practice location:
  • Phone: 831-319-4200
  • Fax:
Mailing address:
  • Phone: 831-462-1060
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number15526
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: