MEDICARE: MR. CARLOS CASTILLO SP. ED. TEACHER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	174400000X	Specialist

General Provider Information

NPI Number	:	1255695193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. CARLOS CASTILLO SP. ED. TEACHER

Provider Business Mailing Address
First Line	:	13111 KEW GARDENS RD APT 4C
Second Line	:
City	:	RICHMOND HILL
State	:	NY
Zip	:	11418-1941
Country	:	US
Telephone Number	:	191-765-1997
Fax Number	:

Provider Business Practice Location Address
First Line	:	13111 KEW GARDENS RD APT 4C
Second Line	:
City	:	RICHMOND HILL
State	:	NY
Zip	:	11418-1941
Country	:	US
Telephone Number	:	191-765-1997
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/26/2012
Last Update Date	:	06/26/2012

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