Provider Demographics
NPI:1962541177
Name:VILLADEL INC
Entity type:Organization
Organization Name:VILLADEL INC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:HERMINIO
Authorized Official - Middle Name:FERNANDEZ
Authorized Official - Last Name:DELEON
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:760-480-1482
Mailing Address - Street 1:6345 CAMINO MARINERO
Mailing Address - Street 2:
Mailing Address - City:SAN CLEMENTE
Mailing Address - State:CA
Mailing Address - Zip Code:92673-7113
Mailing Address - Country:US
Mailing Address - Phone:760-480-1482
Mailing Address - Fax:760-294-8681
Practice Address - Street 1:841 SAINT SAVA PL
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92069-3591
Practice Address - Country:US
Practice Address - Phone:760-480-1482
Practice Address - Fax:760-294-8681
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-05
Last Update Date:2008-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550000132315P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes315P00000XNursing & Custodial Care FacilitiesIntermediate Care Facility, Intellectual Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
CALTC80386FMedicaid