Provider Demographics
NPI:1396360152
Name:TEMECULA VALLEY ADVANCED WOUND CARE, MEDICAL CORPORATION
Entity Type:Organization
Organization Name:TEMECULA VALLEY ADVANCED WOUND CARE, MEDICAL CORPORATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:DR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:PAUL
Authorized Official - Last Name:CARRILLO
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:619-995-3273
Mailing Address - Street 1:11105 MEADOW GLEN WAY E
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-7008
Mailing Address - Country:US
Mailing Address - Phone:619-995-3273
Mailing Address - Fax:
Practice Address - Street 1:27555 YNEZ RD STE 400
Practice Address - Street 2:
Practice Address - City:TEMECULA
Practice Address - State:CA
Practice Address - Zip Code:92591-4679
Practice Address - Country:US
Practice Address - Phone:951-466-6764
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-06-08
Last Update Date:2020-06-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM2500XAmbulatory Health Care FacilitiesClinic/CenterMedical Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1831149749OtherNPPES