Healthcare Provider Details

I. General information

NPI: 1457910952
Provider Name (Legal Business Name): MR. JORGE OMAR ESCAMILLA AVINA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/07/2019
Last Update Date: 06/07/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

751 RANCHEROS DR STE 5
SAN MARCOS CA
92069-3042
US

IV. Provider business mailing address

1400 N JOHNSON AVE STE 101
EL CAJON CA
92020-1651
US

V. Phone/Fax

Practice location:
  • Phone: 760-761-0515
  • Fax: 760-716-0464
Mailing address:
  • Phone: 619-442-0277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: