Provider Demographics
NPI:1770767477
Name:CASTLE ROCK PEDIATRICS AND FAMILY WELLNESS CENTER
Entity type:Organization
Organization Name:CASTLE ROCK PEDIATRICS AND FAMILY WELLNESS CENTER
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRACTITIONER
Authorized Official - Prefix:MRS
Authorized Official - First Name:REINHILD
Authorized Official - Middle Name:
Authorized Official - Last Name:AYOUB
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:360-274-2353
Mailing Address - Street 1:PO BOX 160
Mailing Address - Street 2:
Mailing Address - City:CASTLE ROCK
Mailing Address - State:WA
Mailing Address - Zip Code:98611-0160
Mailing Address - Country:US
Mailing Address - Phone:360-274-2353
Mailing Address - Fax:360-274-2354
Practice Address - Street 1:139 FIRST AVENUE SW
Practice Address - Street 2:
Practice Address - City:CASTLE ROCK
Practice Address - State:WA
Practice Address - Zip Code:98611-0160
Practice Address - Country:US
Practice Address - Phone:360-274-2353
Practice Address - Fax:360-274-2354
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-18
Last Update Date:2008-11-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA601 929 001 11261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA7094261Medicaid
WAGAB23159Medicare PIN
WACH6190Medicare PIN