Provider Demographics
NPI:1932124377
Name:CARRILLO, PETER (PT)
Entity Type:Individual
Prefix:MR
First Name:PETER
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38072 AMATEUR WAY
Mailing Address - Street 2:
Mailing Address - City:BEAUMONT
Mailing Address - State:CA
Mailing Address - Zip Code:92223-8086
Mailing Address - Country:US
Mailing Address - Phone:909-489-5971
Mailing Address - Fax:
Practice Address - Street 1:2595 W FLORIDA AVE
Practice Address - Street 2:
Practice Address - City:HEMET
Practice Address - State:CA
Practice Address - Zip Code:92545-4615
Practice Address - Country:US
Practice Address - Phone:951-487-9317
Practice Address - Fax:951-487-9371
Is Sole Proprietor?:Yes
Enumeration Date:2006-07-13
Last Update Date:2019-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT26426225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ31815ZMedicare ID - Type Unspecified
CAP95927Medicare UPIN