Provider Demographics
NPI:1164930442
Name:BURILLA, RICARDO TECSON
Entity Type:Individual
Prefix:
First Name:RICARDO
Middle Name:TECSON
Last Name:BURILLA
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 1:15440 RAMONA AVE
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-3195
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:15440 RAMONA AVE
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-3195
Practice Address - Country:US
Practice Address - Phone:909-532-4289
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-20
Last Update Date:2018-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA247379164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse