Healthcare Provider Details

I. General information

NPI: 1104745108
Provider Name (Legal Business Name): JESUS MATIAS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/13/2026
Last Update Date: 07/29/2026
Certification Date: 07/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 N ELM ST
ESCONDIDO CA
92025-3431
US

IV. Provider business mailing address

1690 S JUANITA ST
SAN JACINTO CA
92583-5016
US

V. Phone/Fax

Practice location:
  • Phone: 619-573-4245
  • Fax:
Mailing address:
  • Phone: 760-458-6613
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: