Provider Demographics
NPI:1598072225
Name:DECASTRO, MASINA
Entity Type:Individual
Prefix:
First Name:MASINA
Middle Name:
Last Name:DECASTRO
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 1:345 E 4500 S
Mailing Address - Street 2:SUITE #260
Mailing Address - City:MURRAY
Mailing Address - State:UT
Mailing Address - Zip Code:84107-3991
Mailing Address - Country:US
Mailing Address - Phone:801-747-3556
Mailing Address - Fax:801-747-2086
Practice Address - Street 1:345 E 4500 S
Practice Address - Street 2:SUITE #260
Practice Address - City:MURRAY
Practice Address - State:UT
Practice Address - Zip Code:84107-3991
Practice Address - Country:US
Practice Address - Phone:801-747-3556
Practice Address - Fax:801-747-2086
Is Sole Proprietor?:No
Enumeration Date:2010-09-01
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
UT841590529171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT149707149Medicaid