Basic Information
Provider Information | |||||||||
NPI: | 1891811162 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CARRERA | ||||||||
FirstName: | CARLOS | ||||||||
MiddleName: | RAUL | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | A.A. | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 25 WESTMONT DR APT 11 | ||||||||
Address2: |   | ||||||||
City: | ALHAMBRA | ||||||||
State: | CA | ||||||||
PostalCode: | 918012939 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6263931052 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 160 S 7TH AVE | ||||||||
Address2: |   | ||||||||
City: | LA PUENTE | ||||||||
State: | CA | ||||||||
PostalCode: | 917463211 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 6269618971 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 03/21/2007 | ||||||||
LastUpdateDate: | 08/19/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X |   |   | N |   | Other Service Providers | Case Manager/Care Coordinator |   | 225400000X |   |   | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Rehabilitation Practitioner |   |
No ID Information.