Provider Demographics
NPI:1295970796
Name:CARROLL, PHILLIP (CO)
Entity type:Individual
Prefix:
First Name:PHILLIP
Middle Name:
Last Name:CARROLL
Suffix:
Gender:M
Credentials:CO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:693 HI TECH PKWY
Mailing Address - Street 2:
Mailing Address - City:OAKDALE
Mailing Address - State:CA
Mailing Address - Zip Code:95361-9113
Mailing Address - Country:US
Mailing Address - Phone:209-845-8231
Mailing Address - Fax:209-845-2883
Practice Address - Street 1:1130 COFFEE RD
Practice Address - Street 2:SUITE B
Practice Address - City:MODESTO
Practice Address - State:CA
Practice Address - Zip Code:95355-4228
Practice Address - Country:US
Practice Address - Phone:209-549-1000
Practice Address - Fax:209-549-1016
Is Sole Proprietor?:No
Enumeration Date:2008-12-11
Last Update Date:2008-12-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CACO002162222Z00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes222Z00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotist