Healthcare Provider Details

I. General information

NPI: 1952681652
Provider Name (Legal Business Name): LUCY GARCIA-CARRILLO PTA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/25/2011
Last Update Date: 08/25/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 S I ST A
MADERA CA
93637-4660
US

IV. Provider business mailing address

509 1 STREET A
FRESNO CA
93637
US

V. Phone/Fax

Practice location:
  • Phone: 559-673-0114
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2983
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: