Provider Demographics
NPI:1912871781
Name:VILLAREAL, GRANDELYN DAGATAN
Entity type:Individual
Prefix:
First Name:GRANDELYN
Middle Name:DAGATAN
Last Name:VILLAREAL
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 1:8615 KNOTT AVE STE 1
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90620-3870
Mailing Address - Country:US
Mailing Address - Phone:714-236-9355
Mailing Address - Fax:
Practice Address - Street 1:8615 KNOTT AVE STE 1
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90620-3870
Practice Address - Country:US
Practice Address - Phone:714-236-9355
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-10-03
Last Update Date:2025-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAAC14366171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Single Specialty