Provider Demographics
NPI:1447796065
Name:RILLERA, CLEMSON RINO FERNANDEZ (PT)
Entity Type:Individual
Prefix:
First Name:CLEMSON RINO
Middle Name:FERNANDEZ
Last Name:RILLERA
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1870 YOSEMITE AVE
Mailing Address - Street 2:APT. 101
Mailing Address - City:SIMI VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:93063-4272
Mailing Address - Country:US
Mailing Address - Phone:347-218-3379
Mailing Address - Fax:
Practice Address - Street 1:1870 YOSEMITE AVE
Practice Address - Street 2:APT. 101
Practice Address - City:SIMI VALLEY
Practice Address - State:CA
Practice Address - Zip Code:93063-4272
Practice Address - Country:US
Practice Address - Phone:347-218-3379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-07
Last Update Date:2017-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA39731225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAY3565534OtherCALIFORNIA DRIVER'S LICENSE