Healthcare Provider Details

I. General information

NPI: 1720631369
Provider Name (Legal Business Name): ELVIRA PAOLA BALTIERRA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 04/27/2023
Certification Date: 04/27/2023
Deactivation Date: 04/12/2023
Reactivation Date: 04/25/2023

III. Provider practice location address

3491 KURTZ ST STE 150
SAN DIEGO CA
92110-4430
US

IV. Provider business mailing address

3491 KURTZ ST STE 150
SAN DIEGO CA
92110-4430
US

V. Phone/Fax

Practice location:
  • Phone: 619-320-2404
  • Fax:
Mailing address:
  • Phone: 619-320-2404
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: