Provider Demographics
NPI:1215445374
Name:MEDINA, MAYRA ALEJANDRA (BA)
Entity type:Individual
Prefix:
First Name:MAYRA
Middle Name:ALEJANDRA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:BA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:750 E RIALTO AVE SPC 76
Mailing Address - Street 2:
Mailing Address - City:RIALTO
Mailing Address - State:CA
Mailing Address - Zip Code:92376-0285
Mailing Address - Country:US
Mailing Address - Phone:909-269-3490
Mailing Address - Fax:
Practice Address - Street 1:750 E RIALTO AVE SPC 76
Practice Address - Street 2:
Practice Address - City:RIALTO
Practice Address - State:CA
Practice Address - Zip Code:92376-0285
Practice Address - Country:US
Practice Address - Phone:909-269-3490
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-11
Last Update Date:2018-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health