Healthcare Provider Details

I. General information

NPI: 1568226777
Provider Name (Legal Business Name): DIANA LAURA MELIKIDSE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/08/2024
Last Update Date: 09/04/2026
Certification Date: 09/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 W 4TH ST
SAN BERNARDINO CA
92415-0035
US

IV. Provider business mailing address

14698 ONTARIO CIR
FONTANA CA
92336-0402
US

V. Phone/Fax

Practice location:
  • Phone: 909-386-9899
  • Fax:
Mailing address:
  • Phone: 909-441-1189
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code373H00000X
TaxonomyDay Training/Habilitation Specialist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: