Provider Demographics
NPI:1508358367
Name:MEDINA, GLORIA STEPHANIE
Entity Type:Individual
Prefix:
First Name:GLORIA
Middle Name:STEPHANIE
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 1:1330 S STATE ST
Mailing Address - Street 2:
Mailing Address - City:SAN JACINTO
Mailing Address - State:CA
Mailing Address - Zip Code:92583-4942
Mailing Address - Country:US
Mailing Address - Phone:951-487-2650
Mailing Address - Fax:951-487-2660
Practice Address - Street 1:1330 S STATE ST
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4942
Practice Address - Country:US
Practice Address - Phone:951-487-2650
Practice Address - Fax:951-487-2660
Is Sole Proprietor?:No
Enumeration Date:2018-06-06
Last Update Date:2018-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator