Provider Demographics
NPI:1851080360
Name:CARRILLO, FERNANDO N
Entity Type:Individual
Prefix:
First Name:FERNANDO
Middle Name:N
Last Name:CARRILLO
Suffix:
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 1:9613 ARROW RTE STE A
Mailing Address - Street 2:
Mailing Address - City:RANCHO CUCAMONGA
Mailing Address - State:CA
Mailing Address - Zip Code:91730-4552
Mailing Address - Country:US
Mailing Address - Phone:909-491-8664
Mailing Address - Fax:
Practice Address - Street 1:9613 ARROW RTE STE A
Practice Address - Street 2:
Practice Address - City:RANCHO CUCAMONGA
Practice Address - State:CA
Practice Address - Zip Code:91730-4552
Practice Address - Country:US
Practice Address - Phone:909-491-8664
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-02
Last Update Date:2023-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty