Provider Demographics
NPI:1295359230
Name:CASTRO, HAILEY ALYSSA
Entity Type:Individual
Prefix:
First Name:HAILEY
Middle Name:ALYSSA
Last Name:CASTRO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1428 WATER OAK CUT
Mailing Address - Street 2:
Mailing Address - City:MOUNT PLEASANT
Mailing Address - State:SC
Mailing Address - Zip Code:29466-8080
Mailing Address - Country:US
Mailing Address - Phone:505-506-4764
Mailing Address - Fax:
Practice Address - Street 1:2150 NORTHWOODS BLVD UNIT E2
Practice Address - Street 2:
Practice Address - City:NORTH CHARLESTON
Practice Address - State:SC
Practice Address - Zip Code:29406-4043
Practice Address - Country:US
Practice Address - Phone:843-569-3937
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-05
Last Update Date:2020-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SCOPT.2186152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist