MEDICARE: DIVINA PALAFOX LPT

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	167G00000X	Licensed Psychiatric Technician

General Provider Information

NPI Number	:	1912061995
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVINA PALAFOX LPT

Provider Business Mailing Address
First Line	:	6221 VILLAGE GREEN DR
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95210-4607
Country	:	US
Telephone Number	:	209-401-1134
Fax Number	:

Provider Business Practice Location Address
First Line	:	1839 S EL DORADO ST
Second Line	:
City	:	STOCKTON
State	:	CA
Zip	:	95206-2025
Country	:	US
Telephone Number	:	209-463-0872
Fax Number	:	209-466-4446

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

Provider Enumeration Date	:	12/21/2006
Last Update Date	:	06/22/2023

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