Healthcare Provider Details

I. General information

NPI: 1740429661
Provider Name (Legal Business Name): LEANNE CARRILLO P.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/17/2009
Last Update Date: 02/17/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

9975 S EASTERN AVE SUITE 110
LAS VEGAS NV
89183-7949
US

IV. Provider business mailing address

3663 E SUNSET RD SUITE 503
LAS VEGAS NV
89120-3218
US

V. Phone/Fax

Practice location:
  • Phone: 702-434-2800
  • Fax: 702-451-1034
Mailing address:
  • Phone: 702-434-2800
  • Fax: 702-451-1034

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number2182
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: