Healthcare Provider Details

I. General information

NPI: 1386556900
Provider Name (Legal Business Name): CASTLEGATE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/18/2026
Last Update Date: 09/18/2026
Certification Date: 09/17/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11640 WARNER AVE STE 542
FOUNTAIN VALLEY CA
92708-2513
US

IV. Provider business mailing address

PO BOX 3880
COSTA MESA CA
92628
US

V. Phone/Fax

Practice location:
  • Phone: 714-330-2442
  • Fax: 714-494-8636
Mailing address:
  • Phone: 714-330-2442
  • Fax: 714-494-8636

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

Name: NICHOLAS RISSE
Title or Position: CEO
Credential:
Phone: 714-330-2442