=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336637727
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | DAVID ESTABILLO LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/01/2018
-----------------------------------------------------
Last Update Date | 05/01/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2000 W 21ST ST STE E3
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88101-4093
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 954-655-3570
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 1161
-----------------------------------------------------
City | CLOVIS
-----------------------------------------------------
State | NM
-----------------------------------------------------
Zip | 88102-1161
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | MR. DAVID ESTABILLO
-----------------------------------------------------
Credential | CNP
-----------------------------------------------------
Telephone | 954-655-3570
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------