Provider Demographics
NPI:1821656356
Name:CARRILLO, IVON (RD)
Entity Type:Individual
Prefix:
First Name:IVON
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:F
Credentials:RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3910 WASHINGTON PKWY
Mailing Address - Street 2:
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83404-7596
Mailing Address - Country:US
Mailing Address - Phone:208-523-1122
Mailing Address - Fax:208-523-2582
Practice Address - Street 1:3910 WASHINGTON PKWY
Practice Address - Street 2:
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83404-7596
Practice Address - Country:US
Practice Address - Phone:208-523-1122
Practice Address - Fax:208-523-2582
Is Sole Proprietor?:No
Enumeration Date:2019-05-30
Last Update Date:2019-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered