Healthcare Provider Details

I. General information

NPI: 1265893770
Provider Name (Legal Business Name): JUAN ESCAMILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/10/2016
Last Update Date: 04/24/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6711 ARLINGTON AVE
RIVERSIDE CA
92504-1955
US

IV. Provider business mailing address

790 VIA LATA STE 300
COLTON CA
92324-3978
US

V. Phone/Fax

Practice location:
  • Phone: 951-742-6380
  • Fax:
Mailing address:
  • Phone: 909-433-0445
  • Fax: 909-433-0556

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: