Healthcare Provider Details

I. General information

NPI: 1518748979
Provider Name (Legal Business Name): MARIO ESQUIVEL MT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/11/2023
Last Update Date: 10/11/2023
Certification Date: 10/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16025 GALE AVE
CITY OF INDUSTRY CA
91745-1600
US

IV. Provider business mailing address

502 YORBITA RD
LA PUENTE CA
91744-5962
US

V. Phone/Fax

Practice location:
  • Phone: 626-463-8822
  • Fax:
Mailing address:
  • Phone: 626-463-8822
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number94277
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: