Healthcare Provider Details

I. General information

NPI: 1982567566
Provider Name (Legal Business Name): CRYSTAL VALERIE CASTRO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2025
Last Update Date: 12/09/2025
Certification Date: 12/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7425 OLD MAIN HL
LOGAN UT
84322-7425
US

IV. Provider business mailing address

650 S 100 E APT K308
LOGAN UT
84321-7236
US

V. Phone/Fax

Practice location:
  • Phone: 208-431-5774
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number14252264-4810
License Number StateUT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: