Provider Demographics
NPI:1477147718
Name:MURILLO, GIOVANNE
Entity type:Individual
Prefix:
First Name:GIOVANNE
Middle Name:
Last Name:MURILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:158 GENTRY ST
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2100
Mailing Address - Country:US
Mailing Address - Phone:909-599-8222
Mailing Address - Fax:
Practice Address - Street 1:1940 BASELINE RD
Practice Address - Street 2:
Practice Address - City:LA VERNE
Practice Address - State:CA
Practice Address - Zip Code:91750-2148
Practice Address - Country:US
Practice Address - Phone:626-940-8859
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-02-26
Last Update Date:2021-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA19C3OtherMEDI-CAL
CA19BZOtherMEDI-CAL
CA19C1OtherMEDI-CAL
CA19C2OtherMEDI-CAL