Provider Demographics
NPI:1760126254
Name:CARRILLO, JOSE L (LAT, ATC)
Entity Type:Individual
Prefix:
First Name:JOSE
Middle Name:L
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4109 WHITECREST CV
Mailing Address - Street 2:
Mailing Address - City:ROUND ROCK
Mailing Address - State:TX
Mailing Address - Zip Code:78681-1134
Mailing Address - Country:US
Mailing Address - Phone:512-619-0237
Mailing Address - Fax:
Practice Address - Street 1:200 S VISTA RIDGE PKWY
Practice Address - Street 2:
Practice Address - City:CEDAR PARK
Practice Address - State:TX
Practice Address - Zip Code:78613-3901
Practice Address - Country:US
Practice Address - Phone:512-570-1846
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2022-04-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAT22972255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer