Healthcare Provider Details

I. General information

NPI: 1124632658
Provider Name (Legal Business Name): MICHELLE ANN CASTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/02/2020
Last Update Date: 09/02/2020
Certification Date: 09/02/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22093 REDWOOD RD
CASTRO VALLEY CA
94546-6439
US

IV. Provider business mailing address

22093 REDWOOD RD
CASTRO VALLEY CA
94546-6439
US

V. Phone/Fax

Practice location:
  • Phone: 510-305-3489
  • Fax:
Mailing address:
  • Phone: 510-305-3489
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number44819
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: