Provider Demographics
NPI:1538058508
Name:CARRILLO, EDWARD J III
Entity type:Individual
Prefix:
First Name:EDWARD
Middle Name:J
Last Name:CARRILLO
Suffix:III
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 1:3807 PALMETTO AVE
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92377-3505
Mailing Address - Country:US
Mailing Address - Phone:909-319-2590
Mailing Address - Fax:
Practice Address - Street 1:5241 N MAPLE AVE
Practice Address - Street 2:
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93740-0001
Practice Address - Country:US
Practice Address - Phone:559-278-4240
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-07-02
Last Update Date:2025-07-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer