Provider Demographics
NPI:1356524599
Name:MERVAT KELADA M.D. A MEDICAL CORP
Entity type:Organization
Organization Name:MERVAT KELADA M.D. A MEDICAL CORP
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MERVAT
Authorized Official - Middle Name:G
Authorized Official - Last Name:KELADA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:760-562-6633
Mailing Address - Street 1:1001 BLAIR AVE
Mailing Address - Street 2:
Mailing Address - City:CALEXICO
Mailing Address - State:CA
Mailing Address - Zip Code:92231-2308
Mailing Address - Country:US
Mailing Address - Phone:760-562-6633
Mailing Address - Fax:760-768-5037
Practice Address - Street 1:1001 BLAIR AVE
Practice Address - Street 2:
Practice Address - City:CALEXICO
Practice Address - State:CA
Practice Address - Zip Code:92231-2308
Practice Address - Country:US
Practice Address - Phone:760-562-6633
Practice Address - Fax:760-768-5037
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-12-11
Last Update Date:2008-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR1300XAmbulatory Health Care FacilitiesClinic/CenterRural Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARHM53866FMedicaid
CA553866Medicare Oscar/Certification