1154564375 NPI number — TONYA ROSETTA CASTELLANOS IDMT

Table of content: TONYA ROSETTA CASTELLANOS IDMT (NPI 1154564375)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1154564375 NPI number — TONYA ROSETTA CASTELLANOS IDMT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTELLANOS
Provider First Name:
TONYA
Provider Middle Name:
ROSETTA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
IDMT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
CASTELLANOS
Provider Other First Name:
TONYA
Provider Other Middle Name:
ROSETTA
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
IDMT
Provider Other Last Name Type Code:
2

NPI Number Information

NPI Number:
1154564375
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/17/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
104 MAPLE ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ELLSWORTH AFB
Provider Business Mailing Address State Name:
SD
Provider Business Mailing Address Postal Code:
57706-7700
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
508-250-6336
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
PSC 41
Provider Second Line Business Practice Location Address:
UNIT 5210 230
Provider Business Practice Location Address City Name:
APO
Provider Business Practice Location Address State Name:
AE
Provider Business Practice Location Address Postal Code:
09464-9998
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
01638528148
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
04/17/2009

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 1710I1003X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





Copyright © 2007-2025 www.npivalidator.com