=====================================================
General NPI Number Information
=====================================================
NPI Number | 1477680940
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIBERTO CASILLAS ATC, CSCS
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/28/2007
-----------------------------------------------------
Last Update Date | 05/04/2017
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 38397 INNOVATION CT SUITE 106
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92563-2630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-290-8007
-----------------------------------------------------
Fax | 951-575-3626
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 38397 INNOVATION CT SUITE 106
-----------------------------------------------------
City | MURRIETA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92563-2630
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-888-2323
-----------------------------------------------------
Fax | 951-575-3626
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number | AL2230
-----------------------------------------------------
License Number State | FL
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2255A2300X
-----------------------------------------------------
Taxonomy Name | Athletic Trainer
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------