1275031551 NPI number — HYACILLE KAY RIVERA MAYORDOMO PT, DPT

Table of content: HYACILLE KAY RIVERA MAYORDOMO PT, DPT (NPI 1275031551)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1275031551 NPI number — HYACILLE KAY RIVERA MAYORDOMO PT, DPT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MAYORDOMO
Provider First Name:
HYACILLE
Provider Middle Name:
KAY RIVERA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
PT, DPT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
RIVERA MAYORDOMO
Provider Other First Name:
KAY
Provider Other Middle Name:
KAY
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
PT, DPT
Provider Other Last Name Type Code:
5

NPI Number Information

NPI Number:
1275031551
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
02/18/2020
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
325 DISTEL CIR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ALTOS
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
94022-1408
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
582 S SUNNYVALE AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SUNNYVALE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
94086-6125
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
408-523-3060
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
02/01/2018

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 225100000X , with the licence number:  294378 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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