Healthcare Provider Details

I. General information

NPI: 1659088219
Provider Name (Legal Business Name): GEORGINA MEJIA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/03/2022
Last Update Date: 11/03/2022
Certification Date: 11/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17000 VENTURA BLVD STE 100B
ENCINO CA
91316-4109
US

IV. Provider business mailing address

12700 VAN NUYS BLVD APT 300
PACOIMA CA
91331-1625
US

V. Phone/Fax

Practice location:
  • Phone: 818-302-5752
  • Fax:
Mailing address:
  • Phone: 818-671-8869
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225700000X
TaxonomyMassage Therapist
License Number82610
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: