Provider Demographics
NPI:1578995916
Name:DE CASTRO, ELSA GOMEZ
Entity Type:Individual
Prefix:
First Name:ELSA
Middle Name:GOMEZ
Last Name:DE 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 1:2605 RAINBOW GLOW ST
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89030-3709
Mailing Address - Country:US
Mailing Address - Phone:702-630-5009
Mailing Address - Fax:702-631-9821
Practice Address - Street 1:2605 RAINBOW GLOW ST
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89030-3709
Practice Address - Country:US
Practice Address - Phone:702-630-5009
Practice Address - Fax:702-631-9821
Is Sole Proprietor?:Yes
Enumeration Date:2013-08-08
Last Update Date:2013-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
NV225400000XMedicaid