1669134755 NPI number — AMANDA CELESTE CASTRO R1444050921

Table of content: AMANDA CELESTE CASTRO R1444050921 (NPI 1669134755)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1669134755 NPI number — AMANDA CELESTE CASTRO R1444050921

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
CASTRO
Provider First Name:
AMANDA
Provider Middle Name:
CELESTE
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
R1444050921
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:
1669134755
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/06/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
9207 BEACH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LOS ANGELES
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
90002-2426
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
213-458-0118
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2504 W MANCHESTER BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
INGLEWOOD
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
90305-2520
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
323-751-3804
Provider Business Practice Location Address Fax Number:
323-750-5885
Provider Enumeration Date:
10/06/2021

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: 101YA0400X , with the licence number:  R1444050921 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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