=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235950569
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | SKYBLUE AM INC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/19/2024
-----------------------------------------------------
Last Update Date | 10/19/2024
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 14713 PLUMERIA CT
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93314-8522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-369-2527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 14713 PLUMERIA CT
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93314-8522
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-369-2527
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | MR. MANUEL CASTANON JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 661-369-2527
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251T00000X
-----------------------------------------------------
Taxonomy Name | PACE Provider Organization
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------