Healthcare Provider Details

I. General information

NPI: 1457978702
Provider Name (Legal Business Name): LAQUANCE DENISE MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2020
Last Update Date: 01/03/2024
Certification Date: 01/03/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1297 W HOBSONWAY
BLYTHE CA
92225-1423
US

IV. Provider business mailing address

1330 W RAMSEY ST
BANNING CA
92220-4477
US

V. Phone/Fax

Practice location:
  • Phone: 760-921-5000
  • Fax:
Mailing address:
  • Phone: 951-849-1762
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: