Provider Demographics
NPI:1801297254
Name:ESCAMILLA, VIVIAN
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:
Last Name:ESCAMILLA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:531 S CORAL AVE
Mailing Address - Street 2:
Mailing Address - City:COMPTON
Mailing Address - State:CA
Mailing Address - Zip Code:90220-3619
Mailing Address - Country:US
Mailing Address - Phone:323-266-7725
Mailing Address - Fax:
Practice Address - Street 1:453 S INDIANA ST
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90063-3908
Practice Address - Country:US
Practice Address - Phone:323-266-7725
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-04
Last Update Date:2014-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA190081GN3245S0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3245S0500XResidential Treatment FacilitiesSubstance Abuse Rehabilitation FacilitySubstance Abuse Treatment, Children