Healthcare Provider Details

I. General information

NPI: 1396360152
Provider Name (Legal Business Name): TEMECULA VALLEY ADVANCED WOUND CARE, MEDICAL CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/08/2020
Last Update Date: 06/08/2020
Certification Date: 06/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27555 YNEZ RD STE 400
TEMECULA CA
92591-4679
US

IV. Provider business mailing address

11105 MEADOW GLEN WAY E
ESCONDIDO CA
92026-7008
US

V. Phone/Fax

Practice location:
  • Phone: 951-466-6764
  • Fax:
Mailing address:
  • Phone: 619-995-3273
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM2500X
TaxonomyMedical Specialty Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name: DR. ROBERT PAUL CARRILLO
Title or Position: PRESIDENT
Credential: MD
Phone: 619-995-3273