Healthcare Provider Details

I. General information

NPI: 1417657735
Provider Name (Legal Business Name): ANGEL E ESCAMILLA-DIAZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/06/2023
Last Update Date: 03/06/2023
Certification Date: 03/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

861 CORPORATE DR
LEXINGTON KY
40503-5432
US

IV. Provider business mailing address

10100 ELIDA RD
DELPHOS OH
45833-9056
US

V. Phone/Fax

Practice location:
  • Phone: 859-971-2585
  • Fax: 859-971-7594
Mailing address:
  • Phone: 419-685-8010
  • Fax: 419-695-0004

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code104100000X
TaxonomySocial Worker
License Number257613
License Number StateKY
# 2
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number257613
License Number StateKY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: