=====================================================
General NPI Number Information
=====================================================
NPI Number | 1558900563
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MS. KRISTY MARIE DEMERATH
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 12/23/2019
-----------------------------------------------------
Last Update Date | 12/23/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1001 S HALE AVE SPC 54
-----------------------------------------------------
City | ESCONDIDO
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92029-2177
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 760-729-8295
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 41647 BIG SAGE CT
-----------------------------------------------------
City | TEMECULA
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92591-1548
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-764-7080
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 3747A0650X
-----------------------------------------------------
Taxonomy Name | Attendant Care Provider
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------