Healthcare Provider Details

I. General information

NPI: 1174104277
Provider Name (Legal Business Name): LIVING THE DREAM 63 LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/20/2021
Last Update Date: 04/20/2021
Certification Date: 04/20/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3182 DUNBAR LN
TALLAHASSEE FL
32311-3362
US

IV. Provider business mailing address

3182 DUNBAR LN
TALLAHASSEE FL
32311-3362
US

V. Phone/Fax

Practice location:
  • Phone: 850-264-5998
  • Fax: 850-329-2195
Mailing address:
  • Phone: 850-264-5998
  • Fax: 850-329-2195

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: DR. DAVID CASTILLO
Title or Position: OWNER/MANAGER
Credential: MD
Phone: 850-264-5998