Healthcare Provider Details

I. General information

NPI: 1417888199
Provider Name (Legal Business Name): MR. KYLE FRANCIS MANUEL MEJICO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/29/2026
Last Update Date: 05/29/2026
Certification Date: 05/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6245 DE LONGPRE AVE FL 2
LOS ANGELES CA
90028-8253
US

IV. Provider business mailing address

6245 DE LONGPRE AVE FL 2
LOS ANGELES CA
90028-8253
US

V. Phone/Fax

Practice location:
  • Phone: 888-783-1883
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95039540
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: