Healthcare Provider Details

I. General information

NPI: 1104679554
Provider Name (Legal Business Name): LINDA MAEPA TRD
Entity Type: Individual
Gender:
Sole Proprietor: Y

Provider Other Name: GOGO PEBETSE SANGOMA

II. Dates (important events)

Enumeration Date: 04/08/2024
Last Update Date: 04/08/2024
Certification Date: 04/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32 S RAYMOND AVE STE 3
PASADENA CA
91105-1961
US

IV. Provider business mailing address

32 S RAYMOND AVE STE 3
PASADENA CA
91105-1961
US

V. Phone/Fax

Practice location:
  • Phone: 650-241-2424
  • Fax: 650-241-2424
Mailing address:
  • Phone: 650-241-2424
  • Fax: 650-241-2424

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: