=====================================================
General NPI Number Information
=====================================================
NPI Number | 1831709542
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ELA FIESTA
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/06/2020
-----------------------------------------------------
Last Update Date | 08/06/2020
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 323 CAMPUS DR
-----------------------------------------------------
City | ARVIN
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93203-1047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-854-4475
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2804 TYLER ST
-----------------------------------------------------
City | BAKERSFIELD
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 93309-6124
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 661-348-1443
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 208100000X
-----------------------------------------------------
Taxonomy Name | Physical Medicine & Rehabilitation Physician
-----------------------------------------------------
License Number | 50712
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------