Healthcare Provider Details

I. General information

NPI: 1629409990
Provider Name (Legal Business Name): ROBERTO LUIS MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/11/2013
Last Update Date: 12/11/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1007 W AVENUE M14 STE. C
PALMDALE CA
93551-1443
US

IV. Provider business mailing address

5529 LAS BRISAS TER
PALMDALE CA
93551-5749
US

V. Phone/Fax

Practice location:
  • Phone: 661-361-2783
  • Fax:
Mailing address:
  • Phone: 661-361-2783
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: