Provider Demographics
NPI:1235753120
Name:LEO-CASTILLO, KRISTINA S (LMT)
Entity Type:Individual
Prefix:
First Name:KRISTINA
Middle Name:S
Last Name:LEO-CASTILLO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:KRISTINA
Other - Middle Name:
Other - Last Name:NYEMASTER
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:LMT
Mailing Address - Street 1:35008 PALA TEMECULA RD
Mailing Address - Street 2:PMB 156
Mailing Address - City:PALA
Mailing Address - State:CA
Mailing Address - Zip Code:92059
Mailing Address - Country:US
Mailing Address - Phone:760-443-0398
Mailing Address - Fax:
Practice Address - Street 1:1582 W SAN MARCOS BLVD STE 105
Practice Address - Street 2:
Practice Address - City:SAN MARCOS
Practice Address - State:CA
Practice Address - Zip Code:92078-4081
Practice Address - Country:US
Practice Address - Phone:760-443-0398
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA33088225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty