Provider Demographics
NPI:1568144004
Name:CIRILLO, JUSTIN (LMT)
Entity Type:Individual
Prefix:
First Name:JUSTIN
Middle Name:
Last Name:CIRILLO
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1427 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:GOLD HILL
Mailing Address - State:OR
Mailing Address - Zip Code:97525-9737
Mailing Address - Country:US
Mailing Address - Phone:541-324-4312
Mailing Address - Fax:
Practice Address - Street 1:550 SW 6TH ST STE J
Practice Address - Street 2:
Practice Address - City:GRANTS PASS
Practice Address - State:OR
Practice Address - Zip Code:97526-2860
Practice Address - Country:US
Practice Address - Phone:541-324-4312
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-03
Last Update Date:2023-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR27791225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist