Healthcare Provider Details

I. General information

NPI: 1902648587
Provider Name (Legal Business Name): MAURA RAQUEL ESCOBAR GUILLEN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/12/2024
Last Update Date: 06/12/2024
Certification Date: 06/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2677 ZOE AVE
HUNTINGTON PARK CA
90255-4195
US

IV. Provider business mailing address

1701 E TUCKER ST
COMPTON CA
90221-1641
US

V. Phone/Fax

Practice location:
  • Phone: 424-442-9129
  • Fax:
Mailing address:
  • Phone: 424-731-6103
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number6655
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: