Healthcare Provider Details

I. General information

NPI: 1790463578
Provider Name (Legal Business Name): KYLE BERMEJO ESGUERRA OTR/L, OTD, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/11/2023
Last Update Date: 07/30/2024
Certification Date: 07/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10086 PASEO MONTRIL APT 1115
SAN DIEGO CA
92129-3950
US

IV. Provider business mailing address

10086 PASEO MONTRIL APT 1115
SAN DIEGO CA
92129-3950
US

V. Phone/Fax

Practice location:
  • Phone: 310-889-4058
  • Fax:
Mailing address:
  • Phone: 310-889-4058
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number23316
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: