Healthcare Provider Details

I. General information

NPI: 1164089801
Provider Name (Legal Business Name): GISSELLE ESCOBAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/28/2019
Last Update Date: 05/28/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8282 WHITE OAK AVE STE 107
RANCHO CUCAMONGA CA
91730-7681
US

IV. Provider business mailing address

11928 CACTUS CT
FONTANA CA
92337-0798
US

V. Phone/Fax

Practice location:
  • Phone: 909-586-0509
  • Fax:
Mailing address:
  • Phone: 909-697-6872
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2000X
TaxonomyPhysical Therapy Clinic/Center
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: