MEDICARE: CARLOS VALLEJO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program		CA
2	2255A2300X	Athletic Trainer		CA

General Provider Information

NPI Number	:	1295680882
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CARLOS VALLEJO

Provider Business Mailing Address
First Line	:	8356 5TH ST APT 207
Second Line	:
City	:	DOWNEY
State	:	CA
Zip	:	90241-3832
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	4515 PORTOLA PKWY
Second Line	:
City	:	IRVINE
State	:	CA
Zip	:	92620-2200
Country	:	US
Telephone Number	:	562-361-6131
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/28/2026
Last Update Date	:	02/28/2026

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Directions to “ CARLOS VALLEJO ” Practice Location

Language	Start Address	Practice Location

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