Provider Demographics
NPI:1891025235
Name:ALENCASTRO, JEANCARLO (ATC/L)
Entity Type:Individual
Prefix:
First Name:JEANCARLO
Middle Name:
Last Name:ALENCASTRO
Suffix:
Gender:M
Credentials:ATC/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:117 B VALLEYWOOD RD
Mailing Address - Street 2:
Mailing Address - City:TYRONE
Mailing Address - State:GA
Mailing Address - Zip Code:30290
Mailing Address - Country:US
Mailing Address - Phone:678-852-8091
Mailing Address - Fax:
Practice Address - Street 1:777 CLEVELAND AVE SW SUITE 406
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30315-7101
Practice Address - Country:US
Practice Address - Phone:404-228-3112
Practice Address - Fax:404-763-0135
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-07
Last Update Date:2015-01-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAAT0016652255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer