Provider Demographics
NPI:1558682252
Name:CARILLO, CARLOS LINBBAOAN (MEDICAL ASSISTANT 2)
Entity Type:Individual
Prefix:
First Name:CARLOS
Middle Name:LINBBAOAN
Last Name:CARILLO
Suffix:
Gender:M
Credentials:MEDICAL ASSISTANT 2
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4600 BROADWAY STE 1300
Mailing Address - Street 2:
Mailing Address - City:SACRAMENTO
Mailing Address - State:CA
Mailing Address - Zip Code:95820-1527
Mailing Address - Country:US
Mailing Address - Phone:916-874-9355
Mailing Address - Fax:916-874-1732
Practice Address - Street 1:4600 BROADWAY STE 1300
Practice Address - Street 2:
Practice Address - City:SACRAMENTO
Practice Address - State:CA
Practice Address - Zip Code:95820-1527
Practice Address - Country:US
Practice Address - Phone:916-874-9355
Practice Address - Fax:916-874-1732
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-16
Last Update Date:2024-03-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA1366513061Medicaid