Healthcare Provider Details

I. General information

NPI: 1801526520
Provider Name (Legal Business Name): CARLOS CARILLO MUNOZ RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2022
Last Update Date: 06/15/2022
Certification Date: 06/15/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2900 E DEL MAR BLVD
PASADENA CA
91107-4375
US

IV. Provider business mailing address

2900 E DEL MAR BLVD
PASADENA CA
91107-4375
US

V. Phone/Fax

Practice location:
  • Phone: 626-356-2556
  • Fax:
Mailing address:
  • Phone: 626-356-2556
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number538352
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: