Healthcare Provider Details

I. General information

NPI: 1710768254
Provider Name (Legal Business Name): MIRIAM ELIZABETH ESCOBEDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/10/2023
Last Update Date: 10/10/2023
Certification Date: 09/22/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

313 E 6TH ST
PERRIS CA
92570-2460
US

IV. Provider business mailing address

11799 SEBASTIAN WAY STE 103
RANCHO CUCAMONGA CA
91730-0708
US

V. Phone/Fax

Practice location:
  • Phone: 619-252-3771
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number106SOOOOOX
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: