Provider Demographics
NPI:1730577180
Name:CARRILLO, JAIME (ATC)
Entity type:Individual
Prefix:
First Name:JAIME
Middle Name:
Last Name:CARRILLO
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23551 N HIGH RIDGE DR
Mailing Address - Street 2:
Mailing Address - City:LAKE ZURICH
Mailing Address - State:IL
Mailing Address - Zip Code:60047-9048
Mailing Address - Country:US
Mailing Address - Phone:847-721-3609
Mailing Address - Fax:
Practice Address - Street 1:7900 DIVISION ST
Practice Address - Street 2:
Practice Address - City:RIVER FOREST
Practice Address - State:IL
Practice Address - Zip Code:60305-1066
Practice Address - Country:US
Practice Address - Phone:708-524-6224
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-07
Last Update Date:2015-01-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL0960037002255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer