Healthcare Provider Details

I. General information

NPI: 1629835376
Provider Name (Legal Business Name): RONALD CARRILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/29/2024
Last Update Date: 05/08/2025
Certification Date: 05/08/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1235 E ST
FRESNO CA
93706-2024
US

IV. Provider business mailing address

PO BOX 26852
FRESNO CA
93729-6852
US

V. Phone/Fax

Practice location:
  • Phone: 559-268-6261
  • Fax:
Mailing address:
  • Phone: 559-669-9329
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number19822
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: