Provider Demographics
NPI:1710169750
Name:RECILLAS, ROBERTO
Entity Type:Individual
Prefix:MR
First Name:ROBERTO
Middle Name:
Last Name:RECILLAS
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 1:1675 PO BOX
Mailing Address - Street 2:
Mailing Address - City:HAWTHORNE
Mailing Address - State:CA
Mailing Address - Zip Code:90251
Mailing Address - Country:US
Mailing Address - Phone:323-789-5640
Mailing Address - Fax:323-789-5648
Practice Address - Street 1:1675 PO BOX
Practice Address - Street 2:
Practice Address - City:HAWTHORNE
Practice Address - State:CA
Practice Address - Zip Code:90251
Practice Address - Country:US
Practice Address - Phone:323-482-9669
Practice Address - Fax:323-541-1107
Is Sole Proprietor?:Yes
Enumeration Date:2007-11-30
Last Update Date:2010-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251V00000XAgenciesVoluntary or Charitable