Healthcare Provider Details

I. General information

NPI: 1639532914
Provider Name (Legal Business Name): DESTINY ESCOBAR
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2016
Last Update Date: 04/03/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

329 E 149TH ST FL 4
BRONX NY
10451-5601
US

IV. Provider business mailing address

344 BEACH AVE APT 2
BRONX NY
10473-3004
US

V. Phone/Fax

Practice location:
  • Phone: 718-769-2698
  • Fax: 347-402-8192
Mailing address:
  • Phone: 347-717-0619
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: