Healthcare Provider Details

I. General information

NPI: 1770937153
Provider Name (Legal Business Name): CHRISTINA CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/21/2016
Last Update Date: 04/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5080 ANNUNCIATION CIR #103
AVE MARIA FL
34142-9648
US

IV. Provider business mailing address

5080 ANNUNCIATION CIR #103
AVE MARIA FL
34142-9648
US

V. Phone/Fax

Practice location:
  • Phone: 239-357-8462
  • Fax: 888-647-1951
Mailing address:
  • Phone: 239-357-8462
  • Fax: 888-647-1951

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License NumberAP3659
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: