MEDICARE: HEATHER MARIE CARRILLO PT, ATC

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	225100000X	Physical Therapist	PT 28760	CA

General Provider Information

NPI Number	:	1487616215
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER MARIE CARRILLO PT, ATC

Provider Business Mailing Address
First Line	:	1441 SANTA LUCIA RD
Second Line	:	#525
City	:	CHULA VISTA
State	:	CA
Zip	:	91913-1498
Country	:	US
Telephone Number	:	619-454-2958
Fax Number	:	619-454-2958

Provider Business Practice Location Address
First Line	:	5540 LAKE PARK WAY
Second Line	:
City	:	LA MESA
State	:	CA
Zip	:	91942-1607
Country	:	US
Telephone Number	:	619-667-8644
Fax Number	:

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

Provider Enumeration Date	:	04/05/2006
Last Update Date	:	07/08/2007

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