MEDICARE: MJSQUARED LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251T00000X	PACE Provider Organization

General Provider Information

NPI Number	:	1447969894
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MJSQUARED LLC

Provider Business Mailing Address
First Line	:	2570 FERN VALLEY RD
Second Line	:
City	:	CHULA VISTA
State	:	CA
Zip	:	91915-1560
Country	:	US
Telephone Number	:	619-370-8860
Fax Number	:	619-934-8965

Provider Business Practice Location Address
First Line	:	920 SACRAMENTO AVE
Second Line	:
City	:	SPRING VALLEY
State	:	CA
Zip	:	91977-4938
Country	:	US
Telephone Number	:	619-203-7333
Fax Number	:

Authorized Official
Title or Position	:	ADMINISTRATOR
Name	:	JOSEPHINE DIO
Credential	:
Telephone Number	:	323-574-6122

Provider Enumeration Date	:	11/15/2022
Last Update Date	:	11/15/2022

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