Provider Demographics
NPI:1821399304
Name:CARRILLO, RAYNALDO (LMT)
Entity Type:Individual
Prefix:MR
First Name:RAYNALDO
Middle Name:
Last Name:CARRILLO
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 1:1005 N. KROME AVE.
Mailing Address - Street 2:SUITE #125
Mailing Address - City:HOMESTEAD
Mailing Address - State:FL
Mailing Address - Zip Code:33030
Mailing Address - Country:US
Mailing Address - Phone:305-389-1839
Mailing Address - Fax:
Practice Address - Street 1:1005 N. KROME AVE.
Practice Address - Street 2:SUITE #125
Practice Address - City:HOMESTEAD
Practice Address - State:FL
Practice Address - Zip Code:33030
Practice Address - Country:US
Practice Address - Phone:305-389-1839
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-11-15
Last Update Date:2010-11-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA37293225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist