Provider Demographics
NPI:1588019475
Name:DELVALLE, LILLIAM
Entity Type:Individual
Prefix:MRS
First Name:LILLIAM
Middle Name:
Last Name:DELVALLE
Suffix:
Gender:F
Credentials:
Other - Prefix:MR
Other - First Name:CARLOS
Other - Middle Name:O
Other - Last Name:DAVILA
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:VIA DEL PARQUE PA 17
Mailing Address - Street 2:PARQUE DEL RIO
Mailing Address - City:TRUJILLO ALTO
Mailing Address - State:PUERTO RICO
Mailing Address - Zip Code:00976
Mailing Address - Country:UM
Mailing Address - Phone:787-200-4440
Mailing Address - Fax:
Practice Address - Street 1:PA17 VIA DEL PARQUE
Practice Address - Street 2:PARQUE DEL RIO
Practice Address - City:TRUJILLO ALTO
Practice Address - State:PR
Practice Address - Zip Code:00976-6302
Practice Address - Country:US
Practice Address - Phone:787-200-4440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-04-28
Last Update Date:2016-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PRPCVTE4758343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
PR$$$$$$$$$OtherMEDICARE