Provider Demographics
NPI:1609213990
Name:VILLAVICENCIO, LUIS (BA)
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:VILLAVICENCIO
Suffix:
Gender:M
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 N WESTERN AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-5615
Mailing Address - Country:US
Mailing Address - Phone:323-461-3131
Mailing Address - Fax:
Practice Address - Street 1:1325 N WESTERN AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027
Practice Address - Country:US
Practice Address - Phone:323-461-3131
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-05-28
Last Update Date:2019-02-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator