Healthcare Provider Details

I. General information

NPI: 1679158190
Provider Name (Legal Business Name): CORI ESCALANTE CACMT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2021
Last Update Date: 03/16/2021
Certification Date: 03/16/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12333 W WASHINGTON BLVD
LOS ANGELES CA
90066-5509
US

IV. Provider business mailing address

1933 18TH ST APT 104
SANTA MONICA CA
90404-4794
US

V. Phone/Fax

Practice location:
  • Phone: 818-261-7619
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number4836
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: