Healthcare Provider Details

I. General information

NPI: 1821906595
Provider Name (Legal Business Name): BREANNE ESCOBAR
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2026
Last Update Date: 09/01/2026
Certification Date: 09/01/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1618 BONFORTE BLVD STE F
PUEBLO CO
81001-1676
US

IV. Provider business mailing address

140 W 29TH ST # 124
PUEBLO CO
81008-1002
US

V. Phone/Fax

Practice location:
  • Phone: 719-470-0175
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT.0028078
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: