MEDICARE: MAMIE CORRINA ESCOBEDO

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	172V00000X	Community Health Worker		CA
2	175T00000X	Peer Specialist

General Provider Information

NPI Number	:	1316672439
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MAMIE CORRINA ESCOBEDO

Provider Business Mailing Address
First Line	:	2370 SKYWAY DR STE 104
Second Line	:
City	:	SANTA MARIA
State	:	CA
Zip	:	93455-1133
Country	:	US
Telephone Number	:	805-554-3312
Fax Number	:	805-347-6953

Provider Business Practice Location Address
First Line	:	2370 SKYWAY DR STE 104
Second Line	:
City	:	SANTA MARIA
State	:	CA
Zip	:	93455-1133
Country	:	US
Telephone Number	:	805-554-3305
Fax Number	:	805-347-6953

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

Provider Enumeration Date	:	07/21/2022
Last Update Date	:	08/03/2023

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Directions to “ MAMIE CORRINA ESCOBEDO ” Practice Location

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