Healthcare Provider Details

I. General information

NPI: 1316672439
Provider Name (Legal Business Name): MAMIE CORRINA ESCOBEDO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/21/2022
Last Update Date: 08/03/2023
Certification Date: 08/03/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2370 SKYWAY DR STE 104
SANTA MARIA CA
93455-1133
US

IV. Provider business mailing address

2370 SKYWAY DR STE 104
SANTA MARIA CA
93455-1133
US

V. Phone/Fax

Practice location:
  • Phone: 805-554-3305
  • Fax: 805-347-6953
Mailing address:
  • Phone: 805-554-3312
  • Fax: 805-347-6953

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: