Healthcare Provider Details

I. General information

NPI: 1124504170
Provider Name (Legal Business Name): HIPOLITO MURILLO LEP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/12/2018
Last Update Date: 07/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1330 S KNOTT AVE
ANAHEIM CA
92804-4798
US

IV. Provider business mailing address

1330 S KNOTT AVE
ANAHEIM CA
92804-4798
US

V. Phone/Fax

Practice location:
  • Phone: 714-236-3812
  • Fax: 714-828-5325
Mailing address:
  • Phone: 714-236-3812
  • Fax: 714-828-5325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103TS0200X
TaxonomySchool Psychologist
License Number2896
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: