Provider Demographics
NPI:1841235546
Name:CAROLLO, JOHN K (MS, LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:JOHN
Middle Name:K
Last Name:CAROLLO
Suffix:
Gender:M
Credentials:MS, LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8431 FREDERICKSBURG RD FL 5
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78229-3392
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:8431 FREDERICKSBURG RD FL 5
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78229-3392
Practice Address - Country:US
Practice Address - Phone:210-845-6458
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2023-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAT-14252255A2300X
TXAT19292255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
OHAT-1425OtherATHLETIC TRAINING LICENSE
TXAT1929OtherATHLETIC TRAINING LICENSE
069802392OtherNATIONAL CERTIFICATION