Healthcare Provider Details

I. General information

NPI: 1558001685
Provider Name (Legal Business Name): MIRELLA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 03/29/2022
Certification Date: 03/29/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2401 W TURNER RD STE 450
LODI CA
95242-2191
US

IV. Provider business mailing address

7210 MURRAY DR
STOCKTON CA
95210-3339
US

V. Phone/Fax

Practice location:
  • Phone: 209-370-1700
  • Fax:
Mailing address:
  • Phone: 209-373-2800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: