Healthcare Provider Details

I. General information

NPI: 1609385814
Provider Name (Legal Business Name): LUIS V CASTRO PT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2017
Last Update Date: 06/03/2021
Certification Date: 06/03/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

110 N JERRY CLOWER BLVD STE M
YAZOO CITY MS
39194-8669
US

IV. Provider business mailing address

PO BOX 2153 DEPT 1947
BIRMINGHAM AL
35287-1689
US

V. Phone/Fax

Practice location:
  • Phone: 662-763-3750
  • Fax: 662-763-3721
Mailing address:
  • Phone: 901-227-3255
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License NumberPT6262
License Number StateMS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: