Provider Demographics
NPI:1104451855
Name:CASTELO, BLANCA OLIVIA
Entity type:Individual
Prefix:
First Name:BLANCA
Middle Name:OLIVIA
Last Name:CASTELO
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 1:7024 TENBURY CT
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92139-2948
Mailing Address - Country:US
Mailing Address - Phone:619-808-2208
Mailing Address - Fax:
Practice Address - Street 1:4189 THE HILL RD
Practice Address - Street 2:
Practice Address - City:BONITA
Practice Address - State:CA
Practice Address - Zip Code:91902-2343
Practice Address - Country:US
Practice Address - Phone:619-479-4943
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-03
Last Update Date:2020-03-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAB6863287OtherDRIVER LICENSE