Provider Demographics
NPI:1164779658
Name:CODILLA, KEVIN JOHN SABANDAL (LVN)
Entity Type:Individual
Prefix:
First Name:KEVIN JOHN
Middle Name:SABANDAL
Last Name:CODILLA
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13621 ABANA DR
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-1003
Mailing Address - Country:US
Mailing Address - Phone:951-790-9503
Mailing Address - Fax:
Practice Address - Street 1:13621 ABANA DR
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-1003
Practice Address - Country:US
Practice Address - Phone:951-790-9503
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-08-14
Last Update Date:2012-08-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA235190164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse