MEDICARE: MS. ELBA VIRGINIA CARRILLO

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	133N00000X	Nutritionist

General Provider Information

NPI Number	:	1477322881
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. ELBA VIRGINIA CARRILLO

Provider Business Mailing Address
First Line	:	3120 SOUTHWEST FWY
Second Line	:	STE 101 PMB 736978
City	:	HOUSTON
State	:	TX
Zip	:	77098-4520
Country	:	US
Telephone Number	:	832-623-8644
Fax Number	:

Provider Business Practice Location Address
First Line	:	3120 SOUTHWEST FWY
Second Line	:	STE 101 PMB 736978
City	:	HOUSTON
State	:	TX
Zip	:	77098-4520
Country	:	US
Telephone Number	:	832-623-8644
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/27/2023
Last Update Date	:	12/26/2024

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