Healthcare Provider Details

I. General information

NPI: 1639096837
Provider Name (Legal Business Name): OSCAR OMAR CARRILLO MIRANDA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/30/2026
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1290 TAVERN RD
MAMMOTH LAKES CA
93546-6601
US

IV. Provider business mailing address

1290 TAVERN RD
MAMMOTH LAKES CA
93546-6601
US

V. Phone/Fax

Practice location:
  • Phone: 760-924-1740
  • Fax:
Mailing address:
  • Phone: 760-924-1740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: