Provider Demographics
NPI:1255528998
Name:CAROLLO, MANUEL
Entity type:Individual
Prefix:
First Name:MANUEL
Middle Name:
Last Name:CAROLLO
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 1:8454 N 3RD ST
Mailing Address - Street 2:
Mailing Address - City:FRESNO
Mailing Address - State:CA
Mailing Address - Zip Code:93720-2120
Mailing Address - Country:US
Mailing Address - Phone:559-274-0299
Mailing Address - Fax:
Practice Address - Street 1:3467 W SHAW AVE
Practice Address - Street 2:SUITE #102
Practice Address - City:FRESNO
Practice Address - State:CA
Practice Address - Zip Code:93711-3223
Practice Address - Country:US
Practice Address - Phone:559-274-0299
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-26
Last Update Date:2007-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN60602164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6021OtherSTAFF ID NUMBER