Provider Demographics
NPI:1528449139
Name:CARRILLO, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
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 1:111 CORTE MESA AVE
Mailing Address - Street 2:
Mailing Address - City:SAN RAFAEL
Mailing Address - State:CA
Mailing Address - Zip Code:94901-1303
Mailing Address - Country:US
Mailing Address - Phone:415-879-2525
Mailing Address - Fax:
Practice Address - Street 1:111 CORTE MESA AVE
Practice Address - Street 2:
Practice Address - City:SAN RAFAEL
Practice Address - State:CA
Practice Address - Zip Code:94901-1303
Practice Address - Country:US
Practice Address - Phone:415-879-2525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-10
Last Update Date:2015-06-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CASRJH102516761332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies