Healthcare Provider Details

I. General information

NPI: 1720950058
Provider Name (Legal Business Name): JOEL MBEMBA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/17/2025
Last Update Date: 10/24/2025
Certification Date: 09/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

655 PARK CENTER DR
SANTEE CA
92071-6957
US

IV. Provider business mailing address

233 N MOLLISON AVE APT 0
EL CAJON CA
92021-6813
US

V. Phone/Fax

Practice location:
  • Phone: 619-596-5500
  • Fax: 619-596-5501
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number744139
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: