Healthcare Provider Details

I. General information

NPI: 1619717196
Provider Name (Legal Business Name): JAVIER ANTHONY MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 05/30/2024
Certification Date: 05/30/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

210 W CONTINENTAL RD STE 130A
GREEN VALLEY AZ
85622-3546
US

IV. Provider business mailing address

210 W CONTINENTAL RD STE 1340A
GREEN VALLEY AZ
85622-3595
US

V. Phone/Fax

Practice location:
  • Phone: 520-906-8358
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License NumberMT-24444
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: