Healthcare Provider Details

I. General information

NPI: 1578193231
Provider Name (Legal Business Name): VICTOR N/A MEJIA I
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2020
Last Update Date: 01/22/2020
Certification Date: 01/22/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

648 N MERIDIAN ST
HEMET CA
92544-1854
US

IV. Provider business mailing address

648 N MERIDIAN ST
HEMET CA
92544-1854
US

V. Phone/Fax

Practice location:
  • Phone: 951-427-2378
  • Fax:
Mailing address:
  • Phone: 951-427-2378
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code343900000X
TaxonomyNon-emergency Medical Transport (VAN)
License Number46427
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: