Healthcare Provider Details

I. General information

NPI: 1336070309
Provider Name (Legal Business Name): MICHAEL ANTHONY CARRILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2026
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

47915 OASIS ST
INDIO CA
92201-6950
US

IV. Provider business mailing address

84763 CALLE ROJO
COACHELLA CA
92236-2836
US

V. Phone/Fax

Practice location:
  • Phone: 760-863-8600
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number760495
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: