=====================================================
General NPI Number Information
=====================================================
NPI Number | 1144459892
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MEEJUNG BELASCO APNP
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 07/02/2009
-----------------------------------------------------
Last Update Date | 06/11/2013
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4244 RIVERWALK PKWY STE. 170
-----------------------------------------------------
City | RIVERSIDE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92505-8509
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-736-7432
-----------------------------------------------------
Fax | 951-736-7751
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 894830 LOCK BOX 4830
-----------------------------------------------------
City | LOS ANGELES
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 90189-4830
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-853-7451
-----------------------------------------------------
Fax | 909-557-1924
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 3750-033
-----------------------------------------------------
License Number State | WI
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363L00000X
-----------------------------------------------------
Taxonomy Name | Nurse Practitioner
-----------------------------------------------------
License Number | 21604
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------