=====================================================
General NPI Number Information
=====================================================
NPI Number | 1396360152
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | TEMECULA VALLEY ADVANCED WOUND CARE, MEDICAL CORPORATION
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/08/2020
-----------------------------------------------------
Last Update Date | 06/08/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 27555 YNEZ RD STE 400
-----------------------------------------------------
City | TEMECULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92591-4679
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-466-6764
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 11105 MEADOW GLEN WAY E
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92026-7008
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 619-995-3273
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | PRESIDENT
-----------------------------------------------------
Name | DR. ROBERT PAUL CARRILLO
-----------------------------------------------------
Credential | MD
-----------------------------------------------------
Telephone | 619-995-3273
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261QM2500X
-----------------------------------------------------
Taxonomy Name | Medical Specialty Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------