Healthcare Provider Details

I. General information

NPI: 1437586047
Provider Name (Legal Business Name): RAYNARD A CASTILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/27/2013
Last Update Date: 05/07/2024
Certification Date: 05/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16465 SIERRA LAKES PKWY
FONTANA CA
92336-1242
US

IV. Provider business mailing address

1419 ORANGE TREE LN
UPLAND CA
91786-1501
US

V. Phone/Fax

Practice location:
  • Phone: 909-244-9593
  • Fax: 833-903-0337
Mailing address:
  • Phone: 909-973-2388
  • Fax: 909-581-9160

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number803417
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP95009322
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: