Provider Demographics
NPI:1295121705
Name:CASTILLO, LAURENCE
Entity type:Individual
Prefix:
First Name:LAURENCE
Middle Name:
Last Name:CASTILLO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:701 BROKEN ARROW DR
Mailing Address - Street 2:
Mailing Address - City:SILVER CITY
Mailing Address - State:NM
Mailing Address - Zip Code:88061-3308
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:701 BROKEN ARROW DR
Practice Address - Street 2:
Practice Address - City:SILVER CITY
Practice Address - State:NM
Practice Address - Zip Code:88061-3308
Practice Address - Country:US
Practice Address - Phone:575-590-3210
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-10
Last Update Date:2015-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer