Healthcare Provider Details

I. General information

NPI: 1225410848
Provider Name (Legal Business Name): DEBORAH ANN CASTANEDA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/19/2015
Last Update Date: 06/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12350 NATCHEZ AVE.
PALOS HEIGHTS IL
60463
US

IV. Provider business mailing address

12350 NATCHEZ AVE.
PALOS HEIGHTS IL
60463
US

V. Phone/Fax

Practice location:
  • Phone: 708-715-8065
  • Fax:
Mailing address:
  • Phone: 708-715-8065
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number057.003076
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: