Healthcare Provider Details

I. General information

NPI: 1770767477
Provider Name (Legal Business Name): CASTLE ROCK PEDIATRICS AND FAMILY WELLNESS CENTER
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/18/2007
Last Update Date: 11/25/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

139 FIRST AVENUE SW
CASTLE ROCK WA
98611-0160
US

IV. Provider business mailing address

PO BOX 160
CASTLE ROCK WA
98611-0160
US

V. Phone/Fax

Practice location:
  • Phone: 360-274-2353
  • Fax: 360-274-2354
Mailing address:
  • Phone: 360-274-2353
  • Fax: 360-274-2354

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM1300X
TaxonomyMulti-Specialty Clinic/Center
License Number601 929 001 11
License Number StateWA

VIII. Authorized Official

Name: MRS. REINHILD AYOUB
Title or Position: OWNER/PRACTITIONER
Credential:
Phone: 360-274-2353