Provider Demographics
NPI:1750067740
Name:MANDUJANO, EDITH
Entity type:Individual
Prefix:
First Name:EDITH
Middle Name:
Last Name:MANDUJANO
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 1:91115 LAS FLORES WAY
Mailing Address - Street 2:
Mailing Address - City:MECCA
Mailing Address - State:CA
Mailing Address - Zip Code:92254-7007
Mailing Address - Country:US
Mailing Address - Phone:760-396-6273
Mailing Address - Fax:
Practice Address - Street 1:91115 LAS FLORES WAY
Practice Address - Street 2:
Practice Address - City:MECCA
Practice Address - State:CA
Practice Address - Zip Code:92254-7007
Practice Address - Country:US
Practice Address - Phone:760-396-6273
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-06-23
Last Update Date:2023-06-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior TechnicianGroup - Single Specialty