Healthcare Provider Details

I. General information

NPI: 1558956607
Provider Name (Legal Business Name): GERMAN CORONA VILLAGOMEZ RADT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2021
Last Update Date: 03/01/2021
Certification Date: 03/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

737 E GRAND AVE
ESCONDIDO CA
92025-4404
US

IV. Provider business mailing address

737 E GRAND AVE
ESCONDIDO CA
92025-4404
US

V. Phone/Fax

Practice location:
  • Phone: 760-745-8478
  • Fax: 760-745-6852
Mailing address:
  • Phone: 760-745-8478
  • Fax: 760-745-6852

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberD4081577
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: