Provider Demographics
NPI:1083388581
Name:CUBILLAS, MARK LUCK LITO VILLA (RPT)
Entity Type:Individual
Prefix:
First Name:MARK LUCK LITO
Middle Name:VILLA
Last Name:CUBILLAS
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:885 BROADWAY APT 9
Mailing Address - Street 2:
Mailing Address - City:SONOMA
Mailing Address - State:CA
Mailing Address - Zip Code:95476-7027
Mailing Address - Country:US
Mailing Address - Phone:415-629-2020
Mailing Address - Fax:
Practice Address - Street 1:1250 BROADWAY
Practice Address - Street 2:
Practice Address - City:SONOMA
Practice Address - State:CA
Practice Address - Zip Code:95476-7500
Practice Address - Country:US
Practice Address - Phone:707-938-8406
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-08-06
Last Update Date:2021-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA294596225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist