Basic Information
| Provider Information | |||||||||
| NPI: | 1174130165 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTRO | ||||||||
| FirstName: | JOANN | ||||||||
| MiddleName: | C | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | |||||||||
| Credential: | BSW / CHW | ||||||||
| OtherOrganizationName: | |||||||||
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| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 15400 CHOLAME RD | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923922480 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7602435417 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 15863 DESERT CANDLE LN | ||||||||
| Address2: | |||||||||
| City: | VICTORVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923941483 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7609538547 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/24/2020 | ||||||||
| LastUpdateDate: | 07/05/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
| IsOrganizationSubpart: | |||||||||
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| NPICertificationDate: | 07/01/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Other Service Providers | Community Health Worker | 172V00000X | CA | N | Other Service Providers | Community Health Worker |
ID Information
| ID | Type | State | Issuer | Description | 1518207885 | 05 | CA | MEDICAID | 1174130165 | 05 | CA | MEDICAID |