Healthcare Provider Details

I. General information

NPI: 1003071184
Provider Name (Legal Business Name): FERNANDO MEDINA ORTHOTIST
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/28/2008
Last Update Date: 07/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13340 FIRESTONE BLVD UNIT G
SANTA FE SPRINGS CA
90670-5558
US

IV. Provider business mailing address

13340 FIRESTONE BLVD UNIT G
SANTA FE SPRINGS CA
90670-5558
US

V. Phone/Fax

Practice location:
  • Phone: 951-351-0019
  • Fax: 951-351-1279
Mailing address:
  • Phone: 951-351-0019
  • Fax: 951-351-1279

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code222Z00000X
TaxonomyOrthotist
License NumberC36368
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: