Healthcare Provider Details

I. General information

NPI: 1447705629
Provider Name (Legal Business Name): JOHN MEKRUT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/17/2016
Last Update Date: 08/17/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11159 LA MAIDA ST
NORTH HOLLYWOOD CA
91601-4541
US

IV. Provider business mailing address

10413 BLOOMFIELD ST
TOLUCA LAKE CA
91602-2810
US

V. Phone/Fax

Practice location:
  • Phone: 818-605-7669
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2472E0500X
TaxonomyEEG Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: