Provider Demographics
NPI:1104413020
Name:CARRILLO, MARIA ELIZABETH PASCUAL
Entity type:Individual
Prefix:
First Name:MARIA ELIZABETH
Middle Name:PASCUAL
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 1:2581 E TEMPLE AVE APT E
Mailing Address - Street 2:
Mailing Address - City:WEST COVINA
Mailing Address - State:CA
Mailing Address - Zip Code:91792-1890
Mailing Address - Country:US
Mailing Address - Phone:210-502-8100
Mailing Address - Fax:
Practice Address - Street 1:2581 E TEMPLE AVE
Practice Address - Street 2:
Practice Address - City:WEST COVINA
Practice Address - State:CA
Practice Address - Zip Code:91792-1890
Practice Address - Country:US
Practice Address - Phone:210-502-8101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-26
Last Update Date:2020-12-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAY6620389172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes172A00000XOther Service ProvidersDriverGroup - Single Specialty