Healthcare Provider Details

I. General information

NPI: 1851933485
Provider Name (Legal Business Name): KEVIN MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/15/2019
Last Update Date: 09/20/2023
Certification Date: 09/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5811 S SAN PEDRO ST
LOS ANGELES CA
90011-5323
US

IV. Provider business mailing address

5811 S SAN PEDRO ST
LOS ANGELES CA
90011-5323
US

V. Phone/Fax

Practice location:
  • Phone: 323-234-4445
  • Fax:
Mailing address:
  • Phone: 323-234-4445
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 4
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number116782
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: