Provider Demographics
NPI:1821144650
Name:ESCAMILLA, GUILLERMO (DC)
Entity Type:Individual
Prefix:
First Name:GUILLERMO
Middle Name:
Last Name:ESCAMILLA
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:45 SNEDECOR AVE
Mailing Address - Street 2:
Mailing Address - City:BAYPORT
Mailing Address - State:NY
Mailing Address - Zip Code:11705-1716
Mailing Address - Country:US
Mailing Address - Phone:631-475-0211
Mailing Address - Fax:631-475-8277
Practice Address - Street 1:224 E MAIN ST
Practice Address - Street 2:SUITE C
Practice Address - City:PATCHOGUE
Practice Address - State:NY
Practice Address - Zip Code:11772-3124
Practice Address - Country:US
Practice Address - Phone:631-475-0211
Practice Address - Fax:631-475-8277
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYX006481-1111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYX47111Medicare ID - Type UnspecifiedMEDICARE PROVIDER NUMBER