Provider Demographics
NPI:1558789479
Name:CARROLL, BRIAN D
Entity Type:Individual
Prefix:PROF
First Name:BRIAN
Middle Name:D
Last Name:CARROLL
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 1:1718 WINERY RD
Mailing Address - Street 2:
Mailing Address - City:WEST FRANKFORT
Mailing Address - State:IL
Mailing Address - Zip Code:62896-4907
Mailing Address - Country:US
Mailing Address - Phone:618-727-0523
Mailing Address - Fax:
Practice Address - Street 1:1909 W COOLIDGE AVE
Practice Address - Street 2:
Practice Address - City:MARION
Practice Address - State:IL
Practice Address - Zip Code:62959-1097
Practice Address - Country:US
Practice Address - Phone:618-997-5677
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-03-29
Last Update Date:2014-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL164003714133V00000X
MO2014006008133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered