MEDICARE: GINA L ESCAMILLA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	171M00000X	Case Manager/Care Coordinator

General Provider Information

NPI Number	:	1275007551
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GINA L ESCAMILLA

Provider Business Mailing Address
First Line	:	6128 MISTY WOOD DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75217-5605
Country	:	US
Telephone Number	:	972-900-4158
Fax Number	:

Provider Business Practice Location Address
First Line	:	6128 MISTY WOOD DR
Second Line	:
City	:	DALLAS
State	:	TX
Zip	:	75217-5605
Country	:	US
Telephone Number	:	972-900-4158
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/19/2019
Last Update Date	:	01/19/2019

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