Provider Demographics
NPI:1407203854
Name:VILLA, EDGARD EDUARDO JR
Entity Type:Individual
Prefix:MR
First Name:EDGARD
Middle Name:EDUARDO
Last Name:VILLA
Suffix:JR
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:PO BOX 1268
Mailing Address - Street 2:
Mailing Address - City:CRESTLINE
Mailing Address - State:CA
Mailing Address - Zip Code:92325-1268
Mailing Address - Country:US
Mailing Address - Phone:951-816-7849
Mailing Address - Fax:
Practice Address - Street 1:2743 ORANGE ST
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92501-2538
Practice Address - Country:US
Practice Address - Phone:951-788-9515
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-05-16
Last Update Date:2022-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health