Healthcare Provider Details

I. General information

NPI: 1083003537
Provider Name (Legal Business Name): JOSE MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/21/2015
Last Update Date: 01/21/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1090 LANG RD APT. 4207
PORTLAND TX
78374-3101
US

IV. Provider business mailing address

1090 LANG RD APT. 4207
PORTLAND TX
78374-3101
US

V. Phone/Fax

Practice location:
  • Phone: 361-765-8390
  • Fax:
Mailing address:
  • Phone: 361-765-8390
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License Number2082338
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: