MEDICARE: MRS. AZILA KATHERINE SABILE ORTIZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	302F00000X	Exclusive Provider Organization	374602950	CA

General Provider Information

NPI Number	:	1538512744
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. AZILA KATHERINE SABILE ORTIZ

Provider Business Mailing Address
First Line	:	15260 AMALIA ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-1228
Country	:	US
Telephone Number	:	858-366-8787
Fax Number	:	858-240-6200

Provider Business Practice Location Address
First Line	:	15260 AMALIA ST
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92129-1228
Country	:	US
Telephone Number	:	858-366-8787
Fax Number	:	858-240-6200

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	07/22/2016
Last Update Date	:	07/22/2016

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