Healthcare Provider Details

I. General information

NPI: 1619432739
Provider Name (Legal Business Name): MA LOURDES VIEL ESPANTA DO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LOURDES ESPANTA DO

II. Dates (important events)

Enumeration Date: 02/02/2019
Last Update Date: 08/05/2026
Certification Date: 08/05/2026
Deactivation Date: 02/07/2022
Reactivation Date: 08/11/2023

III. Provider practice location address

25455 BARTON RD
LOMA LINDA CA
92354-3128
US

IV. Provider business mailing address

11234 ANDERSON ST
LOMA LINDA CA
92350-1716
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6688
  • Fax:
Mailing address:
  • Phone: 909-558-6688
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number20A23191
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberTLL-2026-008
License Number StateGU

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: