Healthcare Provider Details

I. General information

NPI: 1750164711
Provider Name (Legal Business Name): SHILOH EMERALD RAIN CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2200 TYDD ST
EUREKA CA
95501-1284
US

IV. Provider business mailing address

28 CARROLL RD
LOLETA CA
95551-9705
US

V. Phone/Fax

Practice location:
  • Phone: 707-269-7051
  • Fax:
Mailing address:
  • Phone: 707-396-9530
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95345132
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: