Provider Demographics
NPI:1619581618
Name:DAVILA-TORRES, EDWIN G
Entity Type:Individual
Prefix:
First Name:EDWIN
Middle Name:G
Last Name:DAVILA-TORRES
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 1:16056 HARVEST MOON ST
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-1334
Mailing Address - Country:US
Mailing Address - Phone:626-367-0550
Mailing Address - Fax:
Practice Address - Street 1:4619 ROSEMEAD BLVD
Practice Address - Street 2:
Practice Address - City:ROSEMEAD
Practice Address - State:CA
Practice Address - Zip Code:91770-1478
Practice Address - Country:US
Practice Address - Phone:626-286-1191
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-07
Last Update Date:2020-09-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40356167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician