Healthcare Provider Details

I. General information

NPI: 1689946287
Provider Name (Legal Business Name): MR. VINCENT MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/30/2012
Last Update Date: 11/07/2024
Certification Date: 11/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1020 S ARROYO PKWY
PASADENA CA
91105-3911
US

IV. Provider business mailing address

1020 S ARROYO PKWY
PASADENA CA
91105-3911
US

V. Phone/Fax

Practice location:
  • Phone: 626-403-4888
  • Fax:
Mailing address:
  • Phone: 626-403-4888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-FKTMDL
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: