Healthcare Provider Details

I. General information

NPI: 1912542424
Provider Name (Legal Business Name): THERESA CHURILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2019
Last Update Date: 11/08/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1335 LEE STREET WEST COMPLEX 5TH FLOOR
CHARLOTTESVILLE VA
22911
US

IV. Provider business mailing address

104 LUPINE LN
CHARLOTTESVILLE VA
22911-9023
US

V. Phone/Fax

Practice location:
  • Phone: 434-924-9490
  • Fax:
Mailing address:
  • Phone: 434-906-3034
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code133VN1005X
TaxonomyRenal Nutrition Registered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: