Healthcare Provider Details

I. General information

NPI: 1780371419
Provider Name (Legal Business Name): ELSA MELGOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/21/2023
Last Update Date: 04/21/2023
Certification Date: 04/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

12897 HARBOR BLVD
GARDEN GROVE CA
92840-5808
US

IV. Provider business mailing address

1829 W SAINT ANDREW PL
SANTA ANA CA
92704-4231
US

V. Phone/Fax

Practice location:
  • Phone: 714-636-1143
  • Fax: 714-636-1856
Mailing address:
  • Phone: 714-791-0546
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code183700000X
TaxonomyPharmacy Technician
License Number45309
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: