MEDICARE: IMELDA MEDINA LVN

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	164X00000X	Licensed Vocational Nurse	259253	CA

General Provider Information

NPI Number	:	1972927424
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	IMELDA MEDINA LVN

Provider Business Mailing Address
First Line	:	226 ALTA MESA DR
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-3002
Country	:	US
Telephone Number	:	415-794-9567
Fax Number	:	650-873-8713

Provider Business Practice Location Address
First Line	:	226 ALTA MESA DR
Second Line	:
City	:	SOUTH SAN FRANCISCO
State	:	CA
Zip	:	94080-3002
Country	:	US
Telephone Number	:	415-794-9567
Fax Number	:	650-873-8713

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/04/2014
Last Update Date	:	02/04/2014

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