Provider Demographics
NPI:1902621691
Name:FONTANILLA, ERNESTO
Entity type:Individual
Prefix:
First Name:ERNESTO
Middle Name:
Last Name:FONTANILLA
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 1:350 OE ST
Mailing Address - Street 2:
Mailing Address - City:KIHEI
Mailing Address - State:HI
Mailing Address - Zip Code:96753-8963
Mailing Address - Country:US
Mailing Address - Phone:808-385-6789
Mailing Address - Fax:
Practice Address - Street 1:427 ALA MAKANI ST
Practice Address - Street 2:
Practice Address - City:KAHULUI
Practice Address - State:HI
Practice Address - Zip Code:96732-3571
Practice Address - Country:US
Practice Address - Phone:808-204-2893
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-19
Last Update Date:2024-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician