Healthcare Provider Details

I. General information

NPI: 1780320291
Provider Name (Legal Business Name): MARTHA ESCAMILLA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/08/2022
Last Update Date: 05/08/2022
Certification Date: 05/08/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1261 LINCOLN AVE STE 110
SAN JOSE CA
95125-3030
US

IV. Provider business mailing address

10321 MEADOW LN
SAN JOSE CA
95127-3336
US

V. Phone/Fax

Practice location:
  • Phone: 408-398-1323
  • Fax:
Mailing address:
  • Phone: 408-398-1323
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number1905
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: