=====================================================
General NPI Number Information
=====================================================
NPI Number | 1386556900
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CASTLEGATE LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/18/2026
-----------------------------------------------------
Last Update Date | 09/18/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 11640 WARNER AVE STE 542
-----------------------------------------------------
City | FOUNTAIN VALLEY
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92708-2513
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-330-2442
-----------------------------------------------------
Fax | 714-494-8636
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 3880
-----------------------------------------------------
City | COSTA MESA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92628
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 714-330-2442
-----------------------------------------------------
Fax | 714-494-8636
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CEO
-----------------------------------------------------
Name | NICHOLAS RISSE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 714-330-2442
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 261Q00000X
-----------------------------------------------------
Taxonomy Name | Clinic/Center
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------