MEDICARE: ENRIQUE ESTRADA

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	103K00000X	Behavior Analyst

General Provider Information

NPI Number	:	1548934862
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ENRIQUE ESTRADA

Provider Business Mailing Address
First Line	:	81820 SHADOW PALM AVE APT 88
Second Line	:
City	:	INDIO
State	:	CA
Zip	:	92201-4021
Country	:	US
Telephone Number	:	720-651-3659
Fax Number	:

Provider Business Practice Location Address
First Line	:	6117 BROCKTON AVE STE 105
Second Line	:
City	:	RIVERSIDE
State	:	CA
Zip	:	92506-2282
Country	:	US
Telephone Number	:	951-440-6220
Fax Number	:

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

Provider Enumeration Date	:	08/02/2021
Last Update Date	:	08/02/2021

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Directions to “ ENRIQUE ESTRADA ” Practice Location

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