Provider Demographics
NPI:1356386288
Name:CARRILLO, MATTHEW MANUEL (OWNER)
Entity type:Individual
Prefix:MR
First Name:MATTHEW
Middle Name:MANUEL
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 6501
Mailing Address - Street 2:
Mailing Address - City:LAUREL
Mailing Address - State:MS
Mailing Address - Zip Code:39441-6501
Mailing Address - Country:US
Mailing Address - Phone:601-649-0001
Mailing Address - Fax:601-649-0035
Practice Address - Street 1:434 S 13TH AVE
Practice Address - Street 2:
Practice Address - City:LAUREL
Practice Address - State:MS
Practice Address - Zip Code:39440-4345
Practice Address - Country:US
Practice Address - Phone:601-649-0001
Practice Address - Fax:601-649-0035
Is Sole Proprietor?:Yes
Enumeration Date:2006-06-17
Last Update Date:2007-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS07014/11.11744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MS01339261Medicaid
MS01339261Medicaid