Basic Information
| Provider Information | |||||||||
| NPI: | 1508334871 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | MEBE LOS ANGELES LLC | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8885 RIO SAN DIEGO DR STE 340 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921081669 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197959925 | ||||||||
| FaxNumber: | 8776025087 | ||||||||
| Practice Location | |||||||||
| Address1: | 5250 LANKERSHIM BLVD # 507 | ||||||||
| Address2: | |||||||||
| City: | NORTH HOLLYWOOD | ||||||||
| State: | CA | ||||||||
| PostalCode: | 916013186 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6197959925 | ||||||||
| FaxNumber: | 8776025087 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/05/2018 | ||||||||
| LastUpdateDate: | 04/23/2021 | ||||||||
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| AuthorizedOfficialLastName: | GONZALEZ | ||||||||
| AuthorizedOfficialFirstName: | ESTEBAN | ||||||||
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| AuthorizedOfficialTitleorPosition: | CONTRACTS AND CREDENTIALING | ||||||||
| AuthorizedOfficialTelephone: | 6193230832 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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| AuthorizedOfficialNamePrefix: | MR. | ||||||||
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| NPICertificationDate: | 04/23/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106E00000X | N | 193200000X MULTI-SPECIALTY GROUP | 106S00000X | N | 193200000X MULTI-SPECIALTY GROUP | 224Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapy Assistant | 225X00000X | N | 193200000X MULTI-SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Occupational Therapist | 2355S0801X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Specialist/Technologist | Speech-Language Assistant | 235Z00000X | N | 193200000X MULTI-SPECIALTY GROUP | Speech, Language and Hearing Service Providers | Speech-Language Pathologist | 103K00000X | Y | 193200000X MULTI-SPECIALTY GROUP | Behavioral Health & Social Service Providers | Behavioral Analyst |
No ID Information.