Healthcare Provider Details

I. General information

NPI: 1336812437
Provider Name (Legal Business Name): DESTINEE ESCANDON
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2021
Last Update Date: 07/26/2021
Certification Date: 07/26/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15490 CIVIC DR STE 103
VICTORVILLE CA
92392-2382
US

IV. Provider business mailing address

11607 WINTER PL
ADELANTO CA
92301-6158
US

V. Phone/Fax

Practice location:
  • Phone: 442-327-9172
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: