Healthcare Provider Details

I. General information

NPI: 1093006280
Provider Name (Legal Business Name): MS. ESMERALDA VIRGINIA BERRY
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: ESMERALDA VIRGINIA BERRY P.T.A

II. Dates (important events)

Enumeration Date: 04/22/2011
Last Update Date: 04/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

48303 20TH ST W SPACEW 166
LANCASTER CA
93534-7424
US

IV. Provider business mailing address

48303 20TH ST W SPACE 166
LANCASTER CA
93534-7424
US

V. Phone/Fax

Practice location:
  • Phone: 800-787-6787
  • Fax:
Mailing address:
  • Phone: 661-468-0071
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number4671
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: