Healthcare Provider Details

I. General information

NPI: 1720729494
Provider Name (Legal Business Name): MR. RANDY MEKDARA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/05/2022
Last Update Date: 05/05/2022
Certification Date: 05/05/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

902 S MYRTLE AVE
MONROVIA CA
91016-3427
US

IV. Provider business mailing address

5010 GOLDEN WEST AVE
TEMPLE CITY CA
91780-3934
US

V. Phone/Fax

Practice location:
  • Phone: 626-357-3258
  • Fax:
Mailing address:
  • Phone: 626-246-5286
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YP2500X
TaxonomyProfessional Counselor
License NumberAPCC10859
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License NumberAPCC10859
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: