Healthcare Provider Details

I. General information

NPI: 1619897345
Provider Name (Legal Business Name): MELISSA LICEA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/21/2026
Last Update Date: 07/21/2026
Certification Date: 07/21/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4382 WRIGHT BROTHERS ST
JURUPA VALLEY CA
92509-7831
US

IV. Provider business mailing address

4382 WRIGHT BROTHERS ST
JURUPA VALLEY CA
92509-7831
US

V. Phone/Fax

Practice location:
  • Phone: 951-703-5355
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code302R00000X
TaxonomyHealth Maintenance Organization
License Number4524136
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: