Healthcare Provider Details

I. General information

NPI: 1528535432
Provider Name (Legal Business Name): VANDRIC JON CASTRO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/29/2018
Last Update Date: 05/06/2021
Certification Date: 05/06/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11650 IBERIA PL
SAN DIEGO CA
92128-2406
US

IV. Provider business mailing address

5025 COLLWOOD BLVD # 3221
SAN DIEGO CA
92115-2126
US

V. Phone/Fax

Practice location:
  • Phone: 909-689-4157
  • Fax:
Mailing address:
  • Phone: 971-284-7912
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: