Provider Demographics
NPI:1508615055
Name:CARRILLO, ROBERTO GABRIEL
Entity type:Individual
Prefix:
First Name:ROBERTO
Middle Name:GABRIEL
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 1:2225 CHALLENGER WAY STE 101
Mailing Address - Street 2:
Mailing Address - City:SANTA ROSA
Mailing Address - State:CA
Mailing Address - Zip Code:95407-5400
Mailing Address - Country:US
Mailing Address - Phone:707-565-4938
Mailing Address - Fax:
Practice Address - Street 1:2225 CHALLENGER WAY STE 101
Practice Address - Street 2:
Practice Address - City:SANTA ROSA
Practice Address - State:CA
Practice Address - Zip Code:95407-5400
Practice Address - Country:US
Practice Address - Phone:707-565-4938
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-05-16
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker