Healthcare Provider Details

I. General information

NPI: 1669171856
Provider Name (Legal Business Name): ANGELINA CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2023
Last Update Date: 03/23/2026
Certification Date: 03/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10981 SAN DIEGO MISSION RD STE 110
SAN DIEGO CA
92108-2448
US

IV. Provider business mailing address

10981 SAN DIEGO MISSION RD STE 110
SAN DIEGO CA
92108-2448
US

V. Phone/Fax

Practice location:
  • Phone: 619-889-8160
  • Fax: 619-521-0867
Mailing address:
  • Phone: 619-889-8160
  • Fax: 619-521-0867

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: