Provider Demographics
NPI:1710536313
Name:ILAGAN, KHALILA S (COTA/LVN)
Entity Type:Individual
Prefix:
First Name:KHALILA
Middle Name:S
Last Name:ILAGAN
Suffix:
Gender:F
Credentials:COTA/LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1034 CORDOZO ST
Mailing Address - Street 2:
Mailing Address - City:PERRIS
Mailing Address - State:CA
Mailing Address - Zip Code:92571-7778
Mailing Address - Country:US
Mailing Address - Phone:951-623-2435
Mailing Address - Fax:
Practice Address - Street 1:1034 CORDOZO ST
Practice Address - Street 2:
Practice Address - City:PERRIS
Practice Address - State:CA
Practice Address - Zip Code:92571-7778
Practice Address - Country:US
Practice Address - Phone:951-623-2435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-05
Last Update Date:2019-09-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA4457224Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapy Assistant