Provider Demographics
NPI:1598222648
Name:JACILDO, RICHARD
Entity Type:Individual
Prefix:
First Name:RICHARD
Middle Name:
Last Name:JACILDO
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 1:275 BAKER ST STE A
Mailing Address - Street 2:
Mailing Address - City:COSTA MESA
Mailing Address - State:CA
Mailing Address - Zip Code:92626-4566
Mailing Address - Country:US
Mailing Address - Phone:714-361-6760
Mailing Address - Fax:
Practice Address - Street 1:275 BAKER ST STE A
Practice Address - Street 2:
Practice Address - City:COSTA MESA
Practice Address - State:CA
Practice Address - Zip Code:92626-4566
Practice Address - Country:US
Practice Address - Phone:714-673-6760
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-25
Last Update Date:2023-07-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Yes172V00000XOther Service ProvidersCommunity Health Worker