Provider Demographics
NPI:1265969323
Name:VILLANEDA, IVAN (ATC)
Entity type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:VILLANEDA
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:16135 HARVEST MOON ST
Mailing Address - Street 2:
Mailing Address - City:LA PUENTE
Mailing Address - State:CA
Mailing Address - Zip Code:91744-1337
Mailing Address - Country:US
Mailing Address - Phone:909-295-1320
Mailing Address - Fax:
Practice Address - Street 1:79 NEW MONTGOMERY ST
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94105-3410
Practice Address - Country:US
Practice Address - Phone:909-295-1320
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-18
Last Update Date:2017-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer