Healthcare Provider Details

I. General information

NPI: 1124169982
Provider Name (Legal Business Name): SAMUEL FERNANDO MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/12/2007
Last Update Date: 09/11/2025
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

703 IRELAND CT
JACKSONVILLE NC
28546-1637
US

IV. Provider business mailing address

703 IRELAND CT
JACKSONVILLE NC
28546-1637
US

V. Phone/Fax

Practice location:
  • Phone: 910-353-1518
  • Fax:
Mailing address:
  • Phone: 910-353-1518
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: