Healthcare Provider Details

I. General information

NPI: 1528399565
Provider Name (Legal Business Name): MARC CASTELO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/14/2010
Last Update Date: 01/14/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

150 SAGEWOOD DR
WINTERVILLE GA
30683-1563
US

IV. Provider business mailing address

150 SAGEWOOD DR
WINTERVILLE GA
30683-1563
US

V. Phone/Fax

Practice location:
  • Phone: 706-742-5758
  • Fax: 678-254-1791
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT005958
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: