Healthcare Provider Details

I. General information

NPI: 1245716679
Provider Name (Legal Business Name): LORA LEE ESCAMILLA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/18/2018
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

506 E 2ND ST
RIO GRANDE CITY TX
78582-3810
US

IV. Provider business mailing address

506 E 2ND ST
RIO GRANDE CITY TX
78582-3810
US

V. Phone/Fax

Practice location:
  • Phone: 956-487-8100
  • Fax: 956-487-8155
Mailing address:
  • Phone: 956-487-8100
  • Fax: 956-487-8155

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number38029
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: