Healthcare Provider Details

I. General information

NPI: 1053405985
Provider Name (Legal Business Name): EDGARDO MENVIELLE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/03/2006
Last Update Date: 01/25/2021
Certification Date: 01/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 E DEL MAR BLVD STE 126
PASADENA CA
91105-2551
US

IV. Provider business mailing address

200 E DEL MAR BLVD
PASADENA CA
91105-2544
US

V. Phone/Fax

Practice location:
  • Phone: 626-569-8074
  • Fax: 626-423-6678
Mailing address:
  • Phone: 626-569-8074
  • Fax: 626-423-6678

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0804X
TaxonomyChild & Adolescent Psychiatry Physician
License NumberC43180
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberC43180
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: