MEDICARE: MARIA DEL CARMEN AMEZCUA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	101YA0400X	Addiction (Substance Use Disorder) Counselor

General Provider Information

NPI Number	:	1295089993
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MARIA DEL CARMEN AMEZCUA

Provider Business Mailing Address
First Line	:	680 W MAIN ST
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-2920
Country	:	US
Telephone Number	:	760-482-0864
Fax Number	:	760-482-9185

Provider Business Practice Location Address
First Line	:	680 W MAIN ST
Second Line	:
City	:	EL CENTRO
State	:	CA
Zip	:	92243-2920
Country	:	US
Telephone Number	:	760-482-0864
Fax Number	:	760-482-9185

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/01/2012
Last Update Date	:	11/01/2012

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