Healthcare Provider Details

I. General information

NPI: 1689567349
Provider Name (Legal Business Name): BRYAN STEPHEN CASTILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/02/2025
Last Update Date: 06/02/2025
Certification Date: 06/02/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

350 TERRACINA BLVD
REDLANDS CA
92373-4850
US

IV. Provider business mailing address

11023 COUNTRYVIEW DR
RANCHO CUCAMONGA CA
91730-6699
US

V. Phone/Fax

Practice location:
  • Phone: 909-335-5500
  • Fax:
Mailing address:
  • Phone: 818-797-8528
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95027099
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: