Basic Information
Provider Information
NPI: 1467017590
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ESAREY
FirstName: SHAYLA
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential:  
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 18726 S WESTERN AVE STE 408
Address2:  
City: GARDENA
State: CA
PostalCode: 902483858
CountryCode: US
TelephoneNumber: 3108560800
FaxNumber: 8555682494
Practice Location
Address1: 27349 JEFFERSON AVE STE 204
Address2:  
City: TEMECULA
State: CA
PostalCode: 925905612
CountryCode: US
TelephoneNumber: 8889222843
FaxNumber: 8555682494
Other Information
ProviderEnumerationDate: 05/03/2019
LastUpdateDate: 05/03/2019
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: N
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
106S00000X00009699CAY    

No ID Information.


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