Provider Demographics
NPI:1316659477
Name:CODILLA, REDENTOR JR
Entity type:Individual
Prefix:
First Name:REDENTOR
Middle Name:
Last Name:CODILLA
Suffix:JR
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 1:4013 HERITAGE LN
Mailing Address - Street 2:
Mailing Address - City:CLOVIS
Mailing Address - State:CA
Mailing Address - Zip Code:93619-5098
Mailing Address - Country:US
Mailing Address - Phone:559-203-0105
Mailing Address - Fax:
Practice Address - Street 1:4013 HERITAGE LN
Practice Address - Street 2:
Practice Address - City:CLOVIS
Practice Address - State:CA
Practice Address - Zip Code:93619-5098
Practice Address - Country:US
Practice Address - Phone:559-203-0105
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-21
Last Update Date:2022-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA14757225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist