Provider Demographics
NPI:1407326648
Name:CASTILLO, BRYAN
Entity Type:Individual
Prefix:
First Name:BRYAN
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 1:14715 MAYBERRY DR
Mailing Address - Street 2:
Mailing Address - City:WEST OLIVE
Mailing Address - State:MI
Mailing Address - Zip Code:49460-8423
Mailing Address - Country:US
Mailing Address - Phone:231-633-4450
Mailing Address - Fax:
Practice Address - Street 1:14715 MAYBERRY DR
Practice Address - Street 2:
Practice Address - City:PORT SHELDON
Practice Address - State:MI
Practice Address - Zip Code:49460-4946
Practice Address - Country:US
Practice Address - Phone:231-633-4450
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-30
Last Update Date:2018-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI5501013710225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist