Healthcare Provider Details

I. General information

NPI: 1104114636
Provider Name (Legal Business Name): MRS. PATRICIA CARRILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/19/2011
Last Update Date: 07/19/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2644 W CERMAK RD
CHICAGO IL
60608-3515
US

IV. Provider business mailing address

5118 S RICHMOND ST
CHICAGO IL
60632-2133
US

V. Phone/Fax

Practice location:
  • Phone: 773-805-8314
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171R00000X
TaxonomyInterpreter
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: