Healthcare Provider Details

I. General information

NPI: 1609499482
Provider Name (Legal Business Name): DITER MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/27/2020
Last Update Date: 05/27/2020
Certification Date: 05/27/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13101 W WASHINGTON BLVD STE 238
LOS ANGELES CA
90066-5173
US

IV. Provider business mailing address

13101 W WASHINGTON BLVD STE 238
LOS ANGELES CA
90066-5173
US

V. Phone/Fax

Practice location:
  • Phone: 310-853-8025
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: