1952419608 NPI number — CASTLETON FAMILY PRACTICE LLC

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1952419608 NPI number — CASTLETON FAMILY PRACTICE LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
CASTLETON FAMILY PRACTICE LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
6
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1952419608
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
08/28/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
210 JUPITER LAKES BOULEVARD
Provider Second Line Business Mailing Address:
BUILDING 3000, SUITE 102
Provider Business Mailing Address City Name:
JUPITER
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
33458-7831
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
561-748-5456
Provider Business Mailing Address Fax Number:
561-748-5460

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
210 JUPITER LAKES BOULEVARD
Provider Second Line Business Practice Location Address:
BUILDING 3000, SUITE 102
Provider Business Practice Location Address City Name:
JUPITER
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
33458-7831
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
561-748-5456
Provider Business Practice Location Address Fax Number:
561-748-5460
Provider Enumeration Date:
08/25/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MAY-ANDRIS
Authorized Official First Name:
EMMIEL
Authorized Official Middle Name:
M
Authorized Official Title or Position:
SOLE MEMBER
Authorized Official Telephone Number:
651-748-5456

Provider Taxonomy Codes

  • Taxonomy code: 261QP2300X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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