1598232357 NPI number — VANESSA GUADALUPE CASTRO CM60809994

Table of content: VANESSA GUADALUPE CASTRO CM60809994 (NPI 1598232357)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1598232357 NPI number — VANESSA GUADALUPE CASTRO CM60809994

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTRO
Provider First Name:
VANESSA
Provider Middle Name:
GUADALUPE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CM60809994
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
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:
1598232357
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/30/2018
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
102 S NACHES AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
YAKIMA
Provider Business Mailing Address State Name:
WA
Provider Business Mailing Address Postal Code:
98901-2947
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
509-248-1800
Provider Business Mailing Address Fax Number:
509-576-3076

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
102 S NACHES AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
YAKIMA
Provider Business Practice Location Address State Name:
WA
Provider Business Practice Location Address Postal Code:
98901-2947
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
509-248-1800
Provider Business Practice Location Address Fax Number:
509-576-3076
Provider Enumeration Date:
10/30/2018

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: 2470A2800X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 91-0755984 , issued by the state of ( WA ) . This identifiers is of the category "MEDICAID".




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