Provider Demographics
NPI:1063307940
Name:ESCOBEDO, ADDY
Entity type:Individual
Prefix:
First Name:ADDY
Middle Name:
Last Name:ESCOBEDO
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 1:512 HOLLADAY PL
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-5706
Mailing Address - Country:US
Mailing Address - Phone:323-984-3429
Mailing Address - Fax:
Practice Address - Street 1:14186 CUYAMACA RD
Practice Address - Street 2:
Practice Address - City:APPLE VALLEY
Practice Address - State:CA
Practice Address - Zip Code:92307-5935
Practice Address - Country:US
Practice Address - Phone:323-350-2415
Practice Address - Fax:323-350-2415
Is Sole Proprietor?:Yes
Enumeration Date:2025-06-11
Last Update Date:2025-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA361881127310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility