Healthcare Provider Details

I. General information

NPI: 1053742494
Provider Name (Legal Business Name): MARY GUADALUPE ESCUDERO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 04/25/2025
Certification Date: 04/25/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

474 W VERMONT AVE SUITE 104
ESCONDIDO CA
92025-6584
US

IV. Provider business mailing address

995 GATEWAY CENTER WAY SUITE 300
SAN DIEGO CA
92102
UM

V. Phone/Fax

Practice location:
  • Phone: 760-432-9884
  • Fax:
Mailing address:
  • Phone: 760-432-9884
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: