Healthcare Provider Details

I. General information

NPI: 1508334871
Provider Name (Legal Business Name): MEBE LOS ANGELES LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/05/2018
Last Update Date: 04/23/2021
Certification Date: 04/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5250 LANKERSHIM BLVD # 507
NORTH HOLLYWOOD CA
91601-3186
US

IV. Provider business mailing address

8885 RIO SAN DIEGO DR STE 340
SAN DIEGO CA
92108-1669
US

V. Phone/Fax

Practice location:
  • Phone: 619-795-9925
  • Fax: 877-602-5087
Mailing address:
  • Phone: 619-795-9925
  • Fax: 877-602-5087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code106E00000X
TaxonomyAssistant Behavior Analyst
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code224Z00000X
TaxonomyOccupational Therapy Assistant
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code2355S0801X
TaxonomySpeech-Language Assistant
License Number
License Number State
# 6
Primary TaxonomyN
Taxonomy Code235Z00000X
TaxonomySpeech-Language Pathologist
License Number
License Number State
# 7
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name: MR. ESTEBAN GONZALEZ
Title or Position: CONTRACTS AND CREDENTIALING
Credential:
Phone: 619-323-0832