Provider Demographics
NPI:1629580717
Name:CASTEEL, BRENTON
Entity Type:Individual
Prefix:
First Name:BRENTON
Middle Name:
Last Name:CASTEEL
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 1:4638 E SUMMERHAVEN DR
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85044-4820
Mailing Address - Country:US
Mailing Address - Phone:480-815-1589
Mailing Address - Fax:
Practice Address - Street 1:4638 E SUMMERHAVEN DR
Practice Address - Street 2:
Practice Address - City:PHOENIX
Practice Address - State:AZ
Practice Address - Zip Code:85044-4820
Practice Address - Country:US
Practice Address - Phone:480-815-1589
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-10-29
Last Update Date:2017-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL10375H3104A0630X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ$$$$$$$$$Medicaid