Provider Demographics
NPI:1730546490
Name:PERILLA, MARTHA
Entity type:Individual
Prefix:
First Name:MARTHA
Middle Name:
Last Name:PERILLA
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 1:12084 CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-3975
Mailing Address - Country:US
Mailing Address - Phone:951-282-6250
Mailing Address - Fax:
Practice Address - Street 1:12084 CUSTER ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-3975
Practice Address - Country:US
Practice Address - Phone:951-282-6250
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-01-25
Last Update Date:2016-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA530017163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse