Basic Information
Provider Information | |||||||||
NPI: | 1447418140 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | ESPINOZA | ||||||||
FirstName: | KELLY | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 15095 AMARGOSA RD STE 208 | ||||||||
Address2: |   | ||||||||
City: | VICTORVILLE | ||||||||
State: | CA | ||||||||
PostalCode: | 923941879 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7602454695 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 2450 S ATLANTIC BLVD | ||||||||
Address2: |   | ||||||||
City: | COMMERCE | ||||||||
State: | CA | ||||||||
PostalCode: | 900401200 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3238871917 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/29/2008 | ||||||||
LastUpdateDate: | 12/11/2019 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 12/11/2019 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 172V00000X |   |   | Y |   | Other Service Providers | Community Health Worker |   |
ID Information
ID | Type | State | Issuer | Description | 95-2633765 | 01 | CA | MEDI-CAL | OTHER |