Healthcare Provider Details

I. General information

NPI: 1720752512
Provider Name (Legal Business Name): JACOBO EZEQUIEL CASTILLO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JACOBO EZEQUIEL CASTILLO

II. Dates (important events)

Enumeration Date: 08/04/2021
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1521 FOREST HILL BLVD STE 3B
LAKE CLARKE SHORES FL
33406-6031
US

IV. Provider business mailing address

3001 ROBERT RD
WEST PALM BEACH FL
33405-1337
US

V. Phone/Fax

Practice location:
  • Phone: 561-506-3665
  • Fax: 561-444-2458
Mailing address:
  • Phone: 561-574-6861
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberRBT-21-169038
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: