=====================================================
General NPI Number Information
=====================================================
NPI Number | 1942625108
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | GREGORY CASTRO PT,DPT,ATC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 02/25/2014
-----------------------------------------------------
Last Update Date | 04/18/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 464 N PALACE DR
-----------------------------------------------------
City | GLASSBORO
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 08028-3445
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 610-348-6653
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1561 MEDICAL DR
-----------------------------------------------------
City | POTTSTOWN
-----------------------------------------------------
State | PA
-----------------------------------------------------
Zip | 19464-3218
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
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 | RT005057
-----------------------------------------------------
License Number State | PA
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA01816200
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------