Healthcare Provider Details

I. General information

NPI: 1841702784
Provider Name (Legal Business Name): EPHRAIN MOISES ESPERILLA-LOPEZ LMSW
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2017
Last Update Date: 11/01/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3071 E FRANKLIN RD STE 201
MERIDIAN ID
83642-2376
US

IV. Provider business mailing address

3071 E FRANKLIN RD STE 201
MERIDIAN ID
83642-2376
US

V. Phone/Fax

Practice location:
  • Phone: 208-807-2877
  • Fax: 208-807-2888
Mailing address:
  • Phone: 208-807-2877
  • Fax: 208-807-2888

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number37137
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: