Healthcare Provider Details

I. General information

NPI: 1760267371
Provider Name (Legal Business Name): JESSE CASTILLO DPT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 08/30/2023
Certification Date: 08/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

217 N 2ND E
REXBURG ID
83440-1621
US

IV. Provider business mailing address

217 N 2ND E
REXBURG ID
83440-1621
US

V. Phone/Fax

Practice location:
  • Phone: 208-359-6127
  • Fax: 208-359-9479
Mailing address:
  • Phone: 208-359-6127
  • Fax: 208-359-9479

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT-8804
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: