Healthcare Provider Details

I. General information

NPI: 1750442034
Provider Name (Legal Business Name): MAXIMINO ALFREDO MEJIA L.D.N., R.D., R.D.N
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 12/12/2006
Last Update Date: 10/01/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6521 E MAIN ST
EAU CLAIRE MI
49111-5129
US

IV. Provider business mailing address

6521 E MAIN ST P.O. BOX 37
EAU CLAIRE MI
49111-5129
US

V. Phone/Fax

Practice location:
  • Phone: 269-351-6007
  • Fax:
Mailing address:
  • Phone: 269-351-6007
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code133V00000X
TaxonomyRegistered Dietitian
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: