Provider Demographics
NPI:1952730574
Name:BARILLA, JEFFREY (LMT)
Entity Type:Individual
Prefix:
First Name:JEFFREY
Middle Name:
Last Name:BARILLA
Suffix:
Gender:M
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1116 S RUSSELL ST
Mailing Address - Street 2:
Mailing Address - City:MISSOULA
Mailing Address - State:MT
Mailing Address - Zip Code:59801-3511
Mailing Address - Country:US
Mailing Address - Phone:406-541-1525
Mailing Address - Fax:
Practice Address - Street 1:1116 S RUSSELL ST
Practice Address - Street 2:
Practice Address - City:MISSOULA
Practice Address - State:MT
Practice Address - Zip Code:59801-3511
Practice Address - Country:US
Practice Address - Phone:406-541-1525
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-04
Last Update Date:2013-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MTLMT-LMT-LIC-3118174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
MTBEOtherBE