Healthcare Provider Details

I. General information

NPI: 1639352214
Provider Name (Legal Business Name): HAND & UPPER EXTREMITY SURGERY OF DAYTONA BEACH, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/06/2007
Last Update Date: 11/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

667 BEVILLE RD STE B
SOUTH DAYTONA FL
32119-1955
US

IV. Provider business mailing address

667 BEVILLE RD STE B
SOUTH DAYTONA FL
32119-1955
US

V. Phone/Fax

Practice location:
  • Phone: 386-322-6882
  • Fax: 386-322-6848
Mailing address:
  • Phone: 386-322-6882
  • Fax: 386-322-6848

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0105X
TaxonomySurgery of the Hand (Surgery) Physician
License NumberOS59696
License Number StateFL

VIII. Authorized Official

Name: DR. JUAN CARLOS CASTANEDA
Title or Position: PRESIDENT
Credential: D.O.
Phone: 386-322-6882