Healthcare Provider Details

I. General information

NPI: 1760373971
Provider Name (Legal Business Name): RICARDO MEJIA SALAS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/14/2025
Last Update Date: 07/14/2025
Certification Date: 07/14/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4301 S TACOMA WAY # WA98409
TACOMA WA
98409-4522
US

IV. Provider business mailing address

3333 N VISSCHER ST
TACOMA WA
98407-1539
US

V. Phone/Fax

Practice location:
  • Phone: 253-671-9909
  • Fax:
Mailing address:
  • Phone: 253-324-2039
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberCBT.CB.61655059
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: