Provider Demographics
NPI:1376319244
Name:CARRILLO, MARTIN ALEJANDRO
Entity Type:Individual
Prefix:
First Name:MARTIN
Middle Name:ALEJANDRO
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:177 NE 147TH AVE APT 233
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230-4270
Mailing Address - Country:US
Mailing Address - Phone:661-429-1219
Mailing Address - Fax:
Practice Address - Street 1:23100 PACIFIC HWY S STE 201
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:WA
Practice Address - Zip Code:98198-7281
Practice Address - Country:US
Practice Address - Phone:206-824-9500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-11-30
Last Update Date:2024-01-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WACHIR.CH.61507620111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor