Provider Demographics
NPI:1912542424
Name:CHURILLO, THERESA
Entity Type:Individual
Prefix:
First Name:THERESA
Middle Name:
Last Name:CHURILLO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:104 LUPINE LN
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22911-9023
Mailing Address - Country:US
Mailing Address - Phone:434-906-3034
Mailing Address - Fax:
Practice Address - Street 1:1335 LEE STREET
Practice Address - Street 2:WEST COMPLEX 5TH FLOOR
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22911
Practice Address - Country:US
Practice Address - Phone:434-924-9490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-08
Last Update Date:2019-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes133VN1005XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, RenalGroup - Multi-Specialty
No133V00000XDietary & Nutritional Service ProvidersDietitian, RegisteredGroup - Multi-Specialty