Provider Demographics
NPI:1790310308
Name:SANTILLAN, AMBROSIO RICO
Entity Type:Individual
Prefix:MR
First Name:AMBROSIO
Middle Name:RICO
Last Name:SANTILLAN
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 1:675 DUTTON AVE
Mailing Address - Street 2:
Mailing Address - City:SAN LEANDRO
Mailing Address - State:CA
Mailing Address - Zip Code:94577-2030
Mailing Address - Country:US
Mailing Address - Phone:510-735-7055
Mailing Address - Fax:
Practice Address - Street 1:675 DUTTON AVE
Practice Address - Street 2:
Practice Address - City:SAN LEANDRO
Practice Address - State:CA
Practice Address - Zip Code:94577-2030
Practice Address - Country:US
Practice Address - Phone:510-735-7055
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-04
Last Update Date:2020-03-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program