Healthcare Provider Details

I. General information

NPI: 1356952584
Provider Name (Legal Business Name): JACK MEDRANO MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/12/2020
Last Update Date: 08/12/2020
Certification Date: 08/12/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 ALTA RD
SAN DIEGO CA
92158-0001
US

IV. Provider business mailing address

5530 OVERLAND AVE
SAN DIEGO CA
92123-1260
US

V. Phone/Fax

Practice location:
  • Phone: 619-661-2789
  • Fax: 619-661-2797
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number702870
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: