Healthcare Provider Details

I. General information

NPI: 1972496768
Provider Name (Legal Business Name): LAURA SYDNEY MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/30/2025
Last Update Date: 05/30/2025
Certification Date: 05/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

27169 CA-189 SUITE 2
BLUE JAY CA
92317
US

IV. Provider business mailing address

PO BOX 565
RIMFOREST CA
92378-0565
US

V. Phone/Fax

Practice location:
  • Phone: 909-855-0861
  • Fax:
Mailing address:
  • Phone: 909-800-4488
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number8171
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: