Healthcare Provider Details

I. General information

NPI: 1235306630
Provider Name (Legal Business Name): JOSE M MEZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2008
Last Update Date: 05/14/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2791 GREEN RIVER RD 101
CORONA CA
92882-7426
US

IV. Provider business mailing address

2791 GREEN RIVER RD 101
CORONA CA
92882-7426
US

V. Phone/Fax

Practice location:
  • Phone: 951-279-3222
  • Fax: 951-279-5222
Mailing address:
  • Phone: 951-279-3222
  • Fax: 951-279-5222

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberPSB 31678
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: