Provider Demographics
NPI:1730221482
Name:SANTILLAN, MAYRA VERONICA
Entity type:Individual
Prefix:MRS
First Name:MAYRA
Middle Name:VERONICA
Last Name:SANTILLAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11839 KIRKSTON PL
Mailing Address - Street 2:
Mailing Address - City:VICTORVILLE
Mailing Address - State:CA
Mailing Address - Zip Code:92392-5700
Mailing Address - Country:US
Mailing Address - Phone:626-601-8025
Mailing Address - Fax:
Practice Address - Street 1:2085 RUSTIN AVE # 5
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-509-2400
Practice Address - Fax:951-509-2404
Is Sole Proprietor?:No
Enumeration Date:2007-02-12
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner