Healthcare Provider Details

I. General information

NPI: 1497406359
Provider Name (Legal Business Name): CRAIG CARRILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2022
Last Update Date: 01/14/2022
Certification Date: 01/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8135 PAINTER AVE STE 201
WHITTIER CA
90602-3166
US

IV. Provider business mailing address

13936 MARLAND ST
LA PUENTE CA
91746-2150
US

V. Phone/Fax

Practice location:
  • Phone: 562-698-6600
  • Fax: 562-698-6613
Mailing address:
  • Phone: 626-363-5179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: