Provider Demographics
NPI:1316782519
Name:ESPEJO, FREDERICK
Entity type:Individual
Prefix:
First Name:FREDERICK
Middle Name:
Last Name:ESPEJO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:811 W FLORENCE AVE
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631-4509
Mailing Address - Country:US
Mailing Address - Phone:213-210-9957
Mailing Address - Fax:
Practice Address - Street 1:1030 W WARNER AVE
Practice Address - Street 2:
Practice Address - City:SANTA ANA
Practice Address - State:CA
Practice Address - Zip Code:92707-3147
Practice Address - Country:US
Practice Address - Phone:714-957-0611
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-06-28
Last Update Date:2024-06-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA40804167G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes167G00000XNursing Service ProvidersLicensed Psychiatric Technician