Basic Information
| Provider Information | |||||||||
| NPI: | 1477863561 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | CASTILLO | ||||||||
| FirstName: | SERGIO | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | |||||||||
| NameSuffix: | JR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1330 E COOLEY DR | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803705 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1330 E COOLEY DR | ||||||||
| Address2: | |||||||||
| City: | COLTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 923243905 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9095803705 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/07/2010 | ||||||||
| LastUpdateDate: | 06/30/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YA0400X | C01440115 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Addiction (Substance Use Disorder) |
ID Information
| ID | Type | State | Issuer | Description | 1477863561 | 01 | CA | MEDICAL | OTHER | 1477863561 | 05 | CA | MEDICAID |