Basic Information
Provider Information | |||||||||
NPI: | 1487087763 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | CASTILLO | ||||||||
FirstName: | CARLOS | ||||||||
MiddleName: | RENE | ||||||||
NamePrefix: | MR. | ||||||||
NameSuffix: |   | ||||||||
Credential: | PTA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 871 | ||||||||
Address2: |   | ||||||||
City: | TONTITOWN | ||||||||
State: | AR | ||||||||
PostalCode: | 727700871 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4794446277 | ||||||||
FaxNumber: | 4794446278 | ||||||||
Practice Location | |||||||||
Address1: | 1112 S 48TH ST | ||||||||
Address2: |   | ||||||||
City: | SPRINGDALE | ||||||||
State: | AR | ||||||||
PostalCode: | 727625848 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 4797513900 | ||||||||
FaxNumber: | 4797513011 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/09/2013 | ||||||||
LastUpdateDate: | 08/12/2013 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | PTA 2139 | AR | Y |   | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |   |
No ID Information.