Basic Information
| Provider Information | |||||||||
| NPI: | 1669089546 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | SPENCER | ||||||||
| MiddleName: | ELLIOT | ||||||||
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| Credential: | DPT | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7581 9TH ST N STE 100 | ||||||||
| Address2: | |||||||||
| City: | OAKDALE | ||||||||
| State: | MN | ||||||||
| PostalCode: | 551286635 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6517484338 | ||||||||
| FaxNumber: | 6517482892 | ||||||||
| Practice Location | |||||||||
| Address1: | 1961 CARDINAL LN STE A | ||||||||
| Address2: | |||||||||
| City: | FARIBAULT | ||||||||
| State: | MN | ||||||||
| PostalCode: | 550214354 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5073332986 | ||||||||
| FaxNumber: | 5073332918 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/25/2020 | ||||||||
| LastUpdateDate: | 10/02/2020 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 10/02/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 12057 | MN | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.