Provider Demographics
NPI:1508110461
Name:CALVILLO, LUIS ANGEL JR (PTA)
Entity Type:Individual
Prefix:MR
First Name:LUIS
Middle Name:ANGEL
Last Name:CALVILLO
Suffix:JR
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:246 PLEWS CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-1100
Mailing Address - Country:US
Mailing Address - Phone:909-499-9266
Mailing Address - Fax:
Practice Address - Street 1:246 PLEWS CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-1100
Practice Address - Country:US
Practice Address - Phone:909-499-9266
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-30
Last Update Date:2012-10-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAT8130174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist