Provider Demographics
NPI:1073028775
Name:POLILLO, RUTH JEANETTE
Entity Type:Individual
Prefix:
First Name:RUTH
Middle Name:JEANETTE
Last Name:POLILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 EVELYN DR
Mailing Address - Street 2:
Mailing Address - City:MILLERSBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17061-1258
Mailing Address - Country:US
Mailing Address - Phone:717-692-4708
Mailing Address - Fax:717-692-5464
Practice Address - Street 1:248 GRANITE RUN DR
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:PA
Practice Address - Zip Code:17601-6804
Practice Address - Country:US
Practice Address - Phone:717-560-2917
Practice Address - Fax:717-560-2985
Is Sole Proprietor?:No
Enumeration Date:2017-12-05
Last Update Date:2017-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAPT017991225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist