Healthcare Provider Details

I. General information

NPI: 1609587831
Provider Name (Legal Business Name): HECTOR CARRILLO JR. OD
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/08/2022
Last Update Date: 11/05/2024
Certification Date: 11/05/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1120 W LA VETA AVE STE 100
ORANGE CA
92868-4215
US

IV. Provider business mailing address

15021 ELMBROOK DR
LA MIRADA CA
90638-4702
US

V. Phone/Fax

Practice location:
  • Phone: 714-509-4490
  • Fax:
Mailing address:
  • Phone: 562-305-7539
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code152W00000X
TaxonomyOptometrist
License Number35503
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: