Provider Demographics
NPI:1104123843
Name:MEZA, LUIS ADOLFO
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:ADOLFO
Last Name:MEZA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4547 HARLAN AVE
Mailing Address - Street 2:
Mailing Address - City:BALDWIN PARK
Mailing Address - State:CA
Mailing Address - Zip Code:91706-2229
Mailing Address - Country:US
Mailing Address - Phone:626-485-2568
Mailing Address - Fax:
Practice Address - Street 1:265 S RANDOLPH AVE
Practice Address - Street 2:
Practice Address - City:BREA
Practice Address - State:CA
Practice Address - Zip Code:92821-5754
Practice Address - Country:US
Practice Address - Phone:714-582-2149
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-02-15
Last Update Date:2023-03-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
101YM0800X, 171M00000X
CA101YM0800X
CA1076671041C0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1041C0700XBehavioral Health & Social Service ProvidersSocial WorkerClinical
No101YM0800XBehavioral Health & Social Service ProvidersCounselorMental Health
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAZZZ91892ZOtherSANTA CRUZ COUNTY MEDICARE GROUP PTAN#