Provider Demographics
NPI:1609267137
Name:CARRILLO, EZEQUIEL (BEHAVIORAL HLTH TECH)
Entity Type:Individual
Prefix:
First Name:EZEQUIEL
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:BEHAVIORAL HLTH TECH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:BUIDLING 301 ANDREWS AVENUE
Mailing Address - Street 2:LYSTER ARMY HEALTH CLINIC
Mailing Address - City:FORT RUCKER
Mailing Address - State:AL
Mailing Address - Zip Code:36362-5333
Mailing Address - Country:US
Mailing Address - Phone:334-255-7028
Mailing Address - Fax:
Practice Address - Street 1:BUIDLING 301 ANDREWS AVENUE
Practice Address - Street 2:LYSTER ARMY HEALTH CLINIC
Practice Address - City:FORT RUCKER
Practice Address - State:AL
Practice Address - Zip Code:36362-5333
Practice Address - Country:US
Practice Address - Phone:334-255-7028
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-05
Last Update Date:2015-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other