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General NPI Number Information
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NPI Number | 1366914319
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Entity Type | Individual
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Provider Name | JORDAN MAURO MAITILASSO
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Gender | Male
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Dates
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Enumeration Date | 12/31/2018
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Last Update Date | 08/10/2020
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Provider Practice Location Address
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Address Line | 10159 MISSION GORGE RD STE C
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City | SANTEE
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State | CA
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Zip | 92071-3857
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Country | US
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Telephone | 619-579-0947
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Fax | 619-588-6282
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Provider Business Mailing Address
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Address Line | 625 VAN HOUTEN AVE APT J
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City | EL CAJON
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State | CA
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Zip | 92020-5184
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Country | US
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Telephone | 619-206-7131
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State | CA
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