Healthcare Provider Details

I. General information

NPI: 1851767271
Provider Name (Legal Business Name): GLENN MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/19/2015
Last Update Date: 08/19/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4100 NORMAL ST
SAN DIEGO CA
92103-2653
US

IV. Provider business mailing address

838 GENOA WAY
SAN MARCOS CA
92078-1076
US

V. Phone/Fax

Practice location:
  • Phone: 619-725-8000
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number5820
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: