Provider Demographics
NPI:1346023736
Name:MEDINA, LAURA BOLIO
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:BOLIO
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:510 S VERMONT AVE FL 21
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-1912
Mailing Address - Country:US
Mailing Address - Phone:310-534-1083
Mailing Address - Fax:310-257-0213
Practice Address - Street 1:24330 NARBONNE AVE
Practice Address - Street 2:
Practice Address - City:LOMITA
Practice Address - State:CA
Practice Address - Zip Code:90717-1131
Practice Address - Country:US
Practice Address - Phone:310-534-1083
Practice Address - Fax:310-257-0213
Is Sole Proprietor?:No
Enumeration Date:2023-08-17
Last Update Date:2023-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker