Provider Demographics
NPI:1922349778
Name:CASTILLO, JAIME BRAVO
Entity Type:Individual
Prefix:
First Name:JAIME
Middle Name:BRAVO
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 1:1710 PEPPER ST APT H
Mailing Address - Street 2:
Mailing Address - City:ALHAMBRA
Mailing Address - State:CA
Mailing Address - Zip Code:91801-3188
Mailing Address - Country:US
Mailing Address - Phone:626-230-8506
Mailing Address - Fax:
Practice Address - Street 1:1710 PEPPER ST APT H
Practice Address - Street 2:
Practice Address - City:ALHAMBRA
Practice Address - State:CA
Practice Address - Zip Code:91801-3188
Practice Address - Country:US
Practice Address - Phone:626-230-8506
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-03-04
Last Update Date:2019-11-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA7184OtherMEDI-CAL
CA7667OtherMEDI-CAL
CA7708OtherMEDI-CAL
CA7368OtherMEDI-CAL