Healthcare Provider Details

I. General information

NPI: 1063994564
Provider Name (Legal Business Name): BRYAN ESQUIVEL CORONA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/30/2018
Last Update Date: 08/30/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6400 TUPELO DR
CITRUS HEIGHTS CA
95621-1741
US

IV. Provider business mailing address

14700 WASHINGTON AVE APT 109
SAN LEANDRO CA
94578-4237
US

V. Phone/Fax

Practice location:
  • Phone: 916-729-3098
  • Fax:
Mailing address:
  • Phone: 510-361-4429
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: