Provider Demographics
NPI:1528821329
Name:ILAGAN, MYLA DOMONDON
Entity type:Individual
Prefix:
First Name:MYLA
Middle Name:DOMONDON
Last Name:ILAGAN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4101 FAIRWAY DR
Mailing Address - Street 2:
Mailing Address - City:SOQUEL
Mailing Address - State:CA
Mailing Address - Zip Code:95073-3002
Mailing Address - Country:US
Mailing Address - Phone:831-201-4785
Mailing Address - Fax:831-201-4786
Practice Address - Street 1:4101 FAIRWAY DR
Practice Address - Street 2:
Practice Address - City:SOQUEL
Practice Address - State:CA
Practice Address - Zip Code:95073-3002
Practice Address - Country:US
Practice Address - Phone:831-201-4785
Practice Address - Fax:831-201-4786
Is Sole Proprietor?:Yes
Enumeration Date:2024-02-05
Last Update Date:2024-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA445202879310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility