Healthcare Provider Details

I. General information

NPI: 1104657642
Provider Name (Legal Business Name): MENDRIX MEDICAL ASSOCIATES INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/07/2024
Last Update Date: 04/09/2025
Certification Date: 04/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

18726 S WESTERN AVE STE 320
GARDENA CA
90248-3812
US

IV. Provider business mailing address

8601 LINCOLN BLVD # 180-567
LOS ANGELES CA
90045-3554
US

V. Phone/Fax

Practice location:
  • Phone: 310-773-8975
  • Fax: 702-977-1496
Mailing address:
  • Phone:
  • Fax: 702-977-1496

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code103TC0700X
TaxonomyClinical Psychologist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number
License Number State

VIII. Authorized Official

Name: KACEY CALLISON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 918-237-1281