Healthcare Provider Details

I. General information

NPI: 1104188119
Provider Name (Legal Business Name): CAROLINA MORENO ESCOTO LPT
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/14/2012
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

892 27TH ST
SAN DIEGO CA
92154-1444
US

IV. Provider business mailing address

892 27TH ST
SAN DIEGO CA
92154-1444
US

V. Phone/Fax

Practice location:
  • Phone: 619-575-4687
  • Fax:
Mailing address:
  • Phone: 619-575-4687
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number36527
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: