Healthcare Provider Details

I. General information

NPI: 1205203049
Provider Name (Legal Business Name): OLGA OLIVIA CASTILLO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2015
Last Update Date: 08/27/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1620 CUMMINGS RD
MODESTO CA
95358
US

IV. Provider business mailing address

1620 CUMMINGS RD
MODESTO CA
95358
US

V. Phone/Fax

Practice location:
  • Phone: 209-491-0627
  • Fax: 902-622-1420
Mailing address:
  • Phone: 209-491-0627
  • Fax: 902-622-1420

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: