Basic Information
| Provider Information | |||||||||
| NPI: | 1588801914 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | LUZ | ||||||||
| MiddleName: | MARIA | ||||||||
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| Credential: | CPHW, MA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1511 PUENTE AVE APT 78 | ||||||||
| Address2: | |||||||||
| City: | BALDWIN PARK | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917065936 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3234395622 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 5427 WHITTIER BLVD | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900224101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3238691900 | ||||||||
| FaxNumber: | 3238695362 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/07/2009 | ||||||||
| LastUpdateDate: | 01/08/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X | Y | Other Service Providers | Community Health Worker |
ID Information
| ID | Type | State | Issuer | Description | 1396959060 | 05 | CA | MEDICAID |