=====================================================
General NPI Number Information
=====================================================
NPI Number | 1174924724
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DARYN R CARRILLO BC-HIS, ACA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/12/2014
-----------------------------------------------------
Last Update Date | 04/20/2016
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14201 KENTWOOD BLVD STE 2
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-2472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-952-2727
-----------------------------------------------------
Fax | 760-952-2247
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14201 KENTWOOD BLVD STE 2
-----------------------------------------------------
City | VICTORVILLE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92392-2472
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-952-2727
-----------------------------------------------------
Fax | 760-952-2247
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | HA3245
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 237700000X
-----------------------------------------------------
Taxonomy Name | Hearing Instrument Specialist
-----------------------------------------------------
License Number | 184
-----------------------------------------------------
License Number State | NV
-----------------------------------------------------