Healthcare Provider Details

I. General information

NPI: 1760141089
Provider Name (Legal Business Name): DIANA JEANETTE MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/14/2021
Last Update Date: 12/14/2021
Certification Date: 12/13/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24028 LAKE DR.
CRESTLINE CA
92325-9232
US

IV. Provider business mailing address

PO BOX 1225
CRESTLINE CA
92325-1225
US

V. Phone/Fax

Practice location:
  • Phone: 909-338-3222
  • Fax:
Mailing address:
  • Phone: 909-501-5148
  • 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: