MEDICARE: ACE DERICK ESPINOSA

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	106S00000X	Behavior Technician

General Provider Information

NPI Number	:	1669184529
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ACE DERICK ESPINOSA

Provider Business Mailing Address
First Line	:	455 S 700 E UNIT 4321
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-3886
Country	:	US
Telephone Number	:	862-505-9651
Fax Number	:

Provider Business Practice Location Address
First Line	:	455 S 700 E UNIT 4321
Second Line	:
City	:	SALT LAKE CITY
State	:	UT
Zip	:	84102-3886
Country	:	US
Telephone Number	:	862-505-9651
Fax Number	:

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

Provider Enumeration Date	:	12/21/2022
Last Update Date	:	12/21/2022

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Directions to “ ACE DERICK ESPINOSA ” Practice Location

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