Healthcare Provider Details

I. General information

NPI: 1013459817
Provider Name (Legal Business Name): LUIS ESCAMILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2016
Last Update Date: 11/09/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6177 RIVER CREST DR STE A
RIVERSIDE CA
92507-0728
US

IV. Provider business mailing address

6177 RIVER CREST DR STE A
RIVERSIDE CA
92507-0728
US

V. Phone/Fax

Practice location:
  • Phone: 951-653-4480
  • Fax:
Mailing address:
  • Phone: 951-653-4480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number292380
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: