Provider Demographics
NPI:1720410293
Name:RILLA, DIRCK ANTHONY (CCP)
Entity Type:Individual
Prefix:
First Name:DIRCK
Middle Name:ANTHONY
Last Name:RILLA
Suffix:
Gender:M
Credentials:CCP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2545 CHICAGO AVE
Mailing Address - Street 2:SUITE 417
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-4522
Mailing Address - Country:US
Mailing Address - Phone:612-977-2030
Mailing Address - Fax:612-977-2017
Practice Address - Street 1:2545 CHICAGO AVE
Practice Address - Street 2:SUITE 417
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-4522
Practice Address - Country:US
Practice Address - Phone:612-977-2030
Practice Address - Fax:612-977-2017
Is Sole Proprietor?:No
Enumeration Date:2013-08-06
Last Update Date:2013-08-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL214-000199242T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes242T00000XTechnologists, Technicians & Other Technical Service ProvidersPerfusionist