Provider Demographics
NPI:1649725854
Name:CARRILLO, MARIA
Entity type:Individual
Prefix:
First Name:MARIA
Middle Name:
Last Name:CARRILLO
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 1:6515 ATLANTIC AVE
Mailing Address - Street 2:
Mailing Address - City:BELL
Mailing Address - State:CA
Mailing Address - Zip Code:90201-2521
Mailing Address - Country:US
Mailing Address - Phone:323-773-1992
Mailing Address - Fax:
Practice Address - Street 1:6515 ATLANTIC AVE
Practice Address - Street 2:
Practice Address - City:BELL
Practice Address - State:CA
Practice Address - Zip Code:90201-2521
Practice Address - Country:US
Practice Address - Phone:323-773-1992
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-17
Last Update Date:2017-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA225400000XOtherNON PROFIT ORGANIZATION