Healthcare Provider Details

I. General information

NPI: 1861173080
Provider Name (Legal Business Name): LUIS DAVID MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/31/2023
Last Update Date: 07/31/2023
Certification Date: 07/30/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

103 W GENERAL SCREVEN WAY STE G PMB 1098
HINESVILLE GA
31313
US

IV. Provider business mailing address

1245 CYPRESS FALL CIR
HINESVILLE GA
31313-2881
US

V. Phone/Fax

Practice location:
  • Phone: 912-237-9196
  • Fax:
Mailing address:
  • Phone: 912-237-9196
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: