Provider Demographics
NPI:1477965556
Name:MEDINA, ELVA
Entity Type:Individual
Prefix:
First Name:ELVA
Middle Name:
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 1:21520 PIONEER BLVD
Mailing Address - Street 2:SUITE 110
Mailing Address - City:HAWAIIAN GARDENS
Mailing Address - State:CA
Mailing Address - Zip Code:90716-2603
Mailing Address - Country:US
Mailing Address - Phone:562-246-5700
Mailing Address - Fax:562-246-5701
Practice Address - Street 1:21520 PIONEER BLVD
Practice Address - Street 2:SUITE 110
Practice Address - City:HAWAIIAN GARDENS
Practice Address - State:CA
Practice Address - Zip Code:90716-2603
Practice Address - Country:US
Practice Address - Phone:562-246-5700
Practice Address - Fax:562-246-5701
Is Sole Proprietor?:Yes
Enumeration Date:2014-05-23
Last Update Date:2014-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA172V00000XOtherCOMMUNITY HEALTH WOKER