Healthcare Provider Details

I. General information

NPI: 1104638907
Provider Name (Legal Business Name): EDITH ESPILLER LARA CHW
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2025
Last Update Date: 03/04/2025
Certification Date: 03/04/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2456 10TH ST
MONROE MI
48162-4333
US

IV. Provider business mailing address

2456 10TH ST
MONROE MI
48162-4333
US

V. Phone/Fax

Practice location:
  • Phone: 734-265-6480
  • Fax:
Mailing address:
  • Phone: 734-265-6480
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number135359129
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: