=====================================================
General NPI Number Information
=====================================================
NPI Number | 1326660044
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ESTELLA J MICHAEL
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/15/2020
-----------------------------------------------------
Last Update Date | 05/15/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 30 COUNTRY WOOD DR
-----------------------------------------------------
City | POMONA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91766-4818
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-599-8222
-----------------------------------------------------
Fax | 909-599-8223
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 10730 CHURCH ST APT 368
-----------------------------------------------------
City | RANCHO CUCAMONGA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 91730-6659
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 909-599-8222
-----------------------------------------------------
Fax | 909-599-8223
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171M00000X
-----------------------------------------------------
Taxonomy Name | Case Manager/Care Coordinator
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------