=====================================================
General NPI Number Information
=====================================================
NPI Number | 1912405192
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | LINA PEREIRA MEDEIROS
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/23/2018
-----------------------------------------------------
Last Update Date | 01/28/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 29316 LAKE MIST DR
-----------------------------------------------------
City | LAKE ELSINORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92530-7274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 951-348-0060
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 29316 LAKE MIST DR
-----------------------------------------------------
City | LAKE ELSINORE
-----------------------------------------------------
State | CA
-----------------------------------------------------
Zip | 92530-7274
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone |
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 2081S0010X
-----------------------------------------------------
Taxonomy Name | Sports Medicine (Physical Medicine & Rehabilitation) Physician
-----------------------------------------------------
License Number | 200032726
-----------------------------------------------------
License Number State | CA
-----------------------------------------------------