Healthcare Provider Details

I. General information

NPI: 1275268088
Provider Name (Legal Business Name): JOSE INES MEJIA DOMINGUEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

Provider Other Name: JOSE MEJIA

II. Dates (important events)

Enumeration Date: 07/18/2022
Last Update Date: 12/26/2024
Certification Date: 12/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE # 5
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

9890 COUNTY FARM RD STE 3
RIVERSIDE CA
92503-3678
US

V. Phone/Fax

Practice location:
  • Phone: 951-509-2400
  • Fax: 951-509-2405
Mailing address:
  • Phone: 951-509-2499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: