Healthcare Provider Details

I. General information

NPI: 1992482681
Provider Name (Legal Business Name): RITA K MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/03/2023
Last Update Date: 03/26/2025
Certification Date: 03/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5555 RESERVOIR DR STE 204-A
SAN DIEGO CA
92120-5134
US

IV. Provider business mailing address

5555 RESERVOIR DR STE 204-A
SAN DIEGO CA
92120-5134
US

V. Phone/Fax

Practice location:
  • Phone: 619-822-1800
  • Fax:
Mailing address:
  • Phone: 619-822-1800
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: