Healthcare Provider Details

I. General information

NPI: 1659288132
Provider Name (Legal Business Name): MR. VIDEO ESPEJO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/27/2026
Last Update Date: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101 BENTON ST
LOMA LINDA CA
92357-0001
US

IV. Provider business mailing address

1101 BENTON ST
LOMA LINDA CA
92357-0001
US

V. Phone/Fax

Practice location:
  • Phone: 909-825-7084
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number666393
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: