Healthcare Provider Details

I. General information

NPI: 1255242582
Provider Name (Legal Business Name): COREY CASTONGUAY
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2026
Last Update Date: 09/15/2026
Certification Date: 09/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

452 W MARKET ST
XENIA OH
45385-2815
US

IV. Provider business mailing address

452 W MARKET ST
XENIA OH
45385-2815
US

V. Phone/Fax

Practice location:
  • Phone: 937-376-8700
  • Fax:
Mailing address:
  • Phone: 937-376-8700
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberPRS.007556
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: