Provider Demographics
NPI:1962930545
Name:CARRILLO, FRANCISCO ANGLESZANE
Entity type:Individual
Prefix:
First Name:FRANCISCO
Middle Name:ANGLESZANE
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 1:3761 STOCKER ST STE 106
Mailing Address - Street 2:
Mailing Address - City:VIEW PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90008-5129
Mailing Address - Country:US
Mailing Address - Phone:213-291-5003
Mailing Address - Fax:
Practice Address - Street 1:14112 S KINGSLEY DR
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-3018
Practice Address - Country:US
Practice Address - Phone:310-217-7312
Practice Address - Fax:310-352-3111
Is Sole Proprietor?:Yes
Enumeration Date:2017-05-26
Last Update Date:2021-04-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
225400000X
CA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA225400000XMedicaid