Healthcare Provider Details

I. General information

NPI: 1336327394
Provider Name (Legal Business Name): IVAN ENRIQUE CASTRO EMT-B, HS2
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/01/2008
Last Update Date: 04/02/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

300 E MAIN ST
NORFOLK VA
23510-1753
US

IV. Provider business mailing address

300 E MAIN ST
NORFOLK VA
23510-1753
US

V. Phone/Fax

Practice location:
  • Phone: 562-922-5135
  • Fax:
Mailing address:
  • Phone: 562-922-5135
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License NumberB1688832
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code146N00000X
TaxonomyBasic Emergency Medical Technician
License Number941375
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: