Provider Demographics
NPI:1649855404
Name:BALILO, DALE TIGLAO (RN)
Entity type:Individual
Prefix:
First Name:DALE
Middle Name:TIGLAO
Last Name:BALILO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6108 BLACKTHORNE AVE
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90712-1118
Mailing Address - Country:US
Mailing Address - Phone:619-218-8681
Mailing Address - Fax:
Practice Address - Street 1:6108 BLACKTHORNE AVE
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90712-1118
Practice Address - Country:US
Practice Address - Phone:619-218-8681
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-13
Last Update Date:2021-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95160322163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAD2928760OtherCALIFORNIA REAL ID/DRIVER'S LICENSE