Provider Demographics
NPI:1962058040
Name:MEJIA, LUIS CARLOS (PT,DPT)
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:CARLOS
Last Name:MEJIA
Suffix:
Gender:M
Credentials:PT,DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:350 NEW FIDELITY CT
Mailing Address - Street 2:
Mailing Address - City:GARNER
Mailing Address - State:NC
Mailing Address - Zip Code:27529-2665
Mailing Address - Country:US
Mailing Address - Phone:919-373-2919
Mailing Address - Fax:
Practice Address - Street 1:510 S. WASHINGTON ST.
Practice Address - Street 2:STE A
Practice Address - City:FALLS CHURCH
Practice Address - State:VA
Practice Address - Zip Code:22046
Practice Address - Country:US
Practice Address - Phone:703-992-7255
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-14
Last Update Date:2022-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1315625225100000X
VACP010526T225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist