Healthcare Provider Details

I. General information

NPI: 1174958441
Provider Name (Legal Business Name): JAVIER MELGAREJO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/05/2013
Last Update Date: 09/05/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

CAMP PENDLETON 52 AREA SMART CLINIC BOX 555191
APO AA
92055-5191
US

IV. Provider business mailing address

3710 YONGE ST #5
SAN DIEGO CA
92106-1243
US

V. Phone/Fax

Practice location:
  • Phone: 760-725-7029
  • Fax:
Mailing address:
  • Phone: 209-499-7899
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: