Healthcare Provider Details

I. General information

NPI: 1700440039
Provider Name (Legal Business Name): ALEXIS D MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 05/01/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3875 S WESTERN AVE
LOS ANGELES CA
90062-1105
US

IV. Provider business mailing address

800 S SANTA ANITA AVE
ARCADIA CA
91006-3536
US

V. Phone/Fax

Practice location:
  • Phone: 626-254-5000
  • Fax:
Mailing address:
  • Phone: 626-254-5000
  • 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: