Provider Demographics
NPI:1942006267
Name:CUBILLO, CARLOS
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:
Last Name:CUBILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17862 REED ST
Mailing Address - Street 2:
Mailing Address - City:FONTANA
Mailing Address - State:CA
Mailing Address - Zip Code:92336-4801
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17862 REED ST
Practice Address - Street 2:
Practice Address - City:FONTANA
Practice Address - State:CA
Practice Address - Zip Code:92336-4801
Practice Address - Country:US
Practice Address - Phone:909-200-6464
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-02-19
Last Update Date:2025-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171R00000X, 251S00000X, 171400000X
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No171R00000XOther Service ProvidersInterpreter
No251S00000XAgenciesCommunity/Behavioral Health
No171400000XOther Service ProvidersHealth & Wellness Coach