Basic Information
Provider Information
NPI: 1003305822
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ESQUIVEL
FirstName: SUSANA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: BA
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 6801 LINDLEY AVE
Address2:  
City: RESEDA
State: CA
PostalCode: 913354609
CountryCode: US
TelephoneNumber: 8185688415
FaxNumber:  
Practice Location
Address1: 23502 LYONS AVE STE 304A
Address2:  
City: NEWHALL
State: CA
PostalCode: 913212538
CountryCode: US
TelephoneNumber: 6617020166
FaxNumber:  
Other Information
ProviderEnumerationDate: 05/07/2018
LastUpdateDate: 05/07/2018
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000XD7695255CAY    

No ID Information.


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