Provider Demographics
NPI:1902456866
Name:COBURN-VILLALPANDO, LARRY RAY
Entity Type:Individual
Prefix:
First Name:LARRY
Middle Name:RAY
Last Name:COBURN-VILLALPANDO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14272 HOOVER ST TRLR 113
Mailing Address - Street 2:
Mailing Address - City:WESTMINSTER
Mailing Address - State:CA
Mailing Address - Zip Code:92683-4325
Mailing Address - Country:US
Mailing Address - Phone:714-487-1385
Mailing Address - Fax:
Practice Address - Street 1:14272 HOOVER ST TRLR 113
Practice Address - Street 2:
Practice Address - City:WESTMINSTER
Practice Address - State:CA
Practice Address - Zip Code:92683-4325
Practice Address - Country:US
Practice Address - Phone:714-487-1385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-12
Last Update Date:2019-09-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider