Healthcare Provider Details

I. General information

NPI: 1780401968
Provider Name (Legal Business Name): BRIAN MEJIA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/20/2024
Last Update Date: 09/20/2024
Certification Date: 09/13/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1407 E 7ND ST A100
TACOMA WA
98404
US

IV. Provider business mailing address

2922 S 5TH ST.
TACOMA WA
98409
US

V. Phone/Fax

Practice location:
  • Phone: 253-319-0609
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number61591512
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: