Healthcare Provider Details

I. General information

NPI: 1609094317
Provider Name (Legal Business Name): MARIO MEZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/20/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

830 S OLIVE ST
LOS ANGELES CA
90014-3006
US

IV. Provider business mailing address

PO BOX 341325
ARLETA CA
91334-1325
US

V. Phone/Fax

Practice location:
  • Phone: 213-683-8300
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number4210509
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: