Provider Demographics
NPI:1639932098
Name:EJIGU, ELAINE MEKDELA
Entity Type:Individual
Prefix:
First Name:ELAINE
Middle Name:MEKDELA
Last Name:EJIGU
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MEKDELA
Other - Middle Name:
Other - Last Name:EJIGU
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1774 ZONAL AVE BLDG B
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90033-1064
Mailing Address - Country:US
Mailing Address - Phone:310-221-6336
Mailing Address - Fax:
Practice Address - Street 1:1774 ZONAL AVE BLDG B
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90033-1064
Practice Address - Country:US
Practice Address - Phone:310-221-6336
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-01-30
Last Update Date:2024-01-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker