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General NPI Number Information
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NPI Number | 1568602050
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Entity Type | Organization
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Legal Business Name | VISITING HOME MD
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Dates
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Enumeration Date | 02/24/2009
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Last Update Date | 02/25/2010
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Provider Practice Location Address
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Address Line | 4239 ISABELLE ST
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City | PORTAGE
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State | MI
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Zip | 49024-1770
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Country | US
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Telephone | 269-350-8463
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Fax | 269-382-4808
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Provider Business Mailing Address
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Address Line | 9245 AUSTIN DR
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City | PORTAGE
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State | MI
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Zip | 49002-6403
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Country | US
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Telephone | 917-816-4427
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Fax | 269-382-4808
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | DR. JUVENAL LIPANA CASTILLO
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Credential | MD
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Telephone | 269-350-8463
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 208D00000X
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Taxonomy Name | General Practice Physician
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License Number | 4301087182
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License Number State | MI
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Taxonomy #2
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Taxonomy Code | 208100000X
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Taxonomy Name | Physical Medicine & Rehabilitation Physician
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License Number | 4301087182
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License Number State | MI
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