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General NPI Number Information
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NPI Number | 1730577180
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Entity Type | Individual
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Provider Name | JAIME CARRILLO ATC
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Gender | Male
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Dates
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Enumeration Date | 01/07/2015
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Last Update Date | 01/07/2015
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Provider Practice Location Address
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Address Line | 7900 DIVISION ST
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City | RIVER FOREST
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State | IL
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Zip | 60305-1066
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Country | US
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Telephone | 708-524-6224
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Fax |
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Provider Business Mailing Address
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Address Line | 23551 N HIGH RIDGE DR
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City | LAKE ZURICH
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State | IL
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Zip | 60047-9048
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Country | US
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Telephone | 847-721-3609
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 2255A2300X
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Taxonomy Name | Athletic Trainer
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License Number | 096003700
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License Number State | IL
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