Provider Demographics
NPI:1215711049
Name:VILLAVICENCIO MULET, DAIRON LAZARO
Entity type:Individual
Prefix:
First Name:DAIRON
Middle Name:LAZARO
Last Name:VILLAVICENCIO MULET
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 1:6221 FAIRBANKS RD
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89103-3235
Mailing Address - Country:US
Mailing Address - Phone:702-665-0710
Mailing Address - Fax:
Practice Address - Street 1:6221 FAIRBANKS RD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89103-3235
Practice Address - Country:US
Practice Address - Phone:702-665-0710
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-22
Last Update Date:2023-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician