Healthcare Provider Details

I. General information

NPI: 1427473909
Provider Name (Legal Business Name): MARIO MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/20/2014
Last Update Date: 02/20/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6305 WOODMAN AVE
VAN NUYS CA
91401-2346
US

IV. Provider business mailing address

12408 ARCHWOOD ST APT 5
NORTH HOLLYWOOD CA
91606-1350
US

V. Phone/Fax

Practice location:
  • Phone: 818-908-4999
  • Fax: 818-901-9142
Mailing address:
  • Phone: 818-642-7352
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225400000X
TaxonomyRehabilitation Practitioner
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: