Healthcare Provider Details

I. General information

NPI: 1194351585
Provider Name (Legal Business Name): EDGARD JAYSON ESCOBAR PT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/17/2020
Last Update Date: 03/17/2020
Certification Date: 03/17/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2221 LINCOLN PARK AVE
LOS ANGELES CA
90031-2920
US

IV. Provider business mailing address

17022 WING LN
LA PUENTE CA
91744-4247
US

V. Phone/Fax

Practice location:
  • Phone: 323-276-5700
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number293233
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: