Provider Demographics
NPI:1376729772
Name:VILI, MAA
Entity Type:Individual
Prefix:
First Name:MAA
Middle Name:
Last Name:VILI
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 1:340 E 229TH PL
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-4908
Mailing Address - Country:US
Mailing Address - Phone:310-522-1064
Mailing Address - Fax:
Practice Address - Street 1:2043 242ND ST
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-1115
Practice Address - Country:US
Practice Address - Phone:424-263-4485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-01-15
Last Update Date:2008-01-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAN9429567172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver