Healthcare Provider Details

I. General information

NPI: 1750753257
Provider Name (Legal Business Name): MESA, MEDURI, & ANDERSON, L.L.C.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/22/2015
Last Update Date: 10/22/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2721 55TH AVE
OAKLAND CA
94605-1105
US

IV. Provider business mailing address

2721 55TH AVE
OAKLAND CA
94605-1105
US

V. Phone/Fax

Practice location:
  • Phone: 917-862-2250
  • Fax:
Mailing address:
  • Phone: 917-862-2250
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code252Y00000X
TaxonomyEarly Intervention Provider Agency
License Number
License Number State

VIII. Authorized Official

Name: JUAN RAFAEL MESA
Title or Position: CO-FOUNDER/OWNER
Credential:
Phone: 917-862-2250