MEDICARE: KEISHA LYN CASTIMORE

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	251E00000X	Home Health Agency		SC

General Provider Information

NPI Number	:	1861110025
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEISHA LYN CASTIMORE

Provider Business Mailing Address
First Line	:	1413 HIGHWAY 17 S # 139
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-6040
Country	:	US
Telephone Number	:	910-682-4655
Fax Number	:

Provider Business Practice Location Address
First Line	:	1413 HIGHWAY 17 S # 139
Second Line	:
City	:	SURFSIDE BEACH
State	:	SC
Zip	:	29575-6040
Country	:	US
Telephone Number	:	910-682-4655
Fax Number	:

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

Provider Enumeration Date	:	08/15/2022
Last Update Date	:	08/15/2022

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