MEDICARE: KEN CASTILLO

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	2255A2300X	Athletic Trainer	096.005926	IL

General Provider Information

NPI Number	:	1942169636
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KEN CASTILLO

Provider Business Mailing Address
First Line	:	1400 ARENA DR
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-4330
Country	:	US
Telephone Number	:	858-775-0641
Fax Number	:	858-775-0641

Provider Business Practice Location Address
First Line	:	1400 ARENA DR
Second Line	:
City	:	CARBONDALE
State	:	IL
Zip	:	62901-4330
Country	:	US
Telephone Number	:	858-775-0641
Fax Number	:

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

Provider Enumeration Date	:	01/19/2026
Last Update Date	:	01/19/2026

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Directions to “ KEN CASTILLO ” Practice Location

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