Healthcare Provider Details

I. General information

NPI: 1538752779
Provider Name (Legal Business Name): MR. JUSTIN LUIS MEDRANO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/18/2021
Last Update Date: 07/25/2024
Certification Date: 07/25/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S SANTA ANITA AVE
ARCADIA CA
91006-3536
US

IV. Provider business mailing address

800 S SANTA ANITA AVE
ARCADIA CA
91006-3536
US

V. Phone/Fax

Practice location:
  • Phone: 877-722-2737
  • Fax: 831-425-1905
Mailing address:
  • Phone: 877-722-2737
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: