Healthcare Provider Details

I. General information

NPI: 1518673698
Provider Name (Legal Business Name): MICHAEL A CARRILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/23/2023
Last Update Date: 08/09/2023
Certification Date: 08/09/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1916 W TUDOR LN
HANFORD CA
93230-8934
US

IV. Provider business mailing address

1840 S CENTRAL ST
VISALIA CA
93277-4418
US

V. Phone/Fax

Practice location:
  • Phone: 559-589-5028
  • Fax:
Mailing address:
  • Phone: 559-471-4050
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: