Provider Demographics
NPI:1114187218
Name:CARRILLO, NORELL (PT)
Entity Type:Individual
Prefix:MR
First Name:NORELL
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:805 AEROVISTA PL
Mailing Address - Street 2:201
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93401-7919
Mailing Address - Country:US
Mailing Address - Phone:805-788-0805
Mailing Address - Fax:805-788-0845
Practice Address - Street 1:8200 STOCKDALE HWY
Practice Address - Street 2:STE B-1
Practice Address - City:BAKERSFIELD
Practice Address - State:CA
Practice Address - Zip Code:93311-1091
Practice Address - Country:US
Practice Address - Phone:661-827-8959
Practice Address - Fax:661-827-1779
Is Sole Proprietor?:No
Enumeration Date:2008-06-11
Last Update Date:2010-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33266225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CABW255ZMedicare PIN