Healthcare Provider Details

I. General information

NPI: 1801355425
Provider Name (Legal Business Name): THEODORE ESCALANTI RADT-1 R1235121016
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/13/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3539 COLLEGE AVE
SAN DIEGO CA
92115-7032
US

IV. Provider business mailing address

3539 COLLEGE AVE
SAN DIEGO CA
92115-7032
US

V. Phone/Fax

Practice location:
  • Phone: 619-813-3788
  • Fax:
Mailing address:
  • Phone: 619-813-3788
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1235121016
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: