MEDICARE: MARIA ELIZABETH PASCUAL CARRILLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	172A00000X	Driver	Y6620389	CA

General Provider Information

NPI Number	:	1104413020
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA ELIZABETH PASCUAL CARRILLO

Provider Business Mailing Address
First Line	:	2581 E TEMPLE AVE APT E
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-1890
Country	:	US
Telephone Number	:	210-502-8100
Fax Number	:

Provider Business Practice Location Address
First Line	:	2581 E TEMPLE AVE
Second Line	:
City	:	WEST COVINA
State	:	CA
Zip	:	91792-1890
Country	:	US
Telephone Number	:	210-502-8101
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/26/2020
Last Update Date	:	12/26/2020

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