Healthcare Provider Details

I. General information

NPI: 1275609778
Provider Name (Legal Business Name): MARK ALAN ESPINOSA ATC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/27/2006
Last Update Date: 10/06/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

900 UNIVERSITY AVE
RIVERSIDE CA
92521-9800
US

IV. Provider business mailing address

306 S CENTER ST
REDLANDS CA
92373-5178
US

V. Phone/Fax

Practice location:
  • Phone: 951-990-0794
  • Fax:
Mailing address:
  • Phone: 951-990-7940
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number990994
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number070302185
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: