Provider Demographics
NPI:1750442034
Name:MEJIA, MAXIMINO ALFREDO (LDN, RD, RDN)
Entity type:Individual
Prefix:DR
First Name:MAXIMINO
Middle Name:ALFREDO
Last Name:MEJIA
Suffix:
Gender:M
Credentials:LDN, RD, RDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6521 E MAIN ST
Mailing Address - Street 2:P.O. BOX 37
Mailing Address - City:EAU CLAIRE
Mailing Address - State:MI
Mailing Address - Zip Code:49111-5129
Mailing Address - Country:US
Mailing Address - Phone:269-351-6007
Mailing Address - Fax:
Practice Address - Street 1:6521 E MAIN ST
Practice Address - Street 2:
Practice Address - City:EAU CLAIRE
Practice Address - State:MI
Practice Address - Zip Code:49111-5129
Practice Address - Country:US
Practice Address - Phone:269-351-6007
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-12-12
Last Update Date:2013-10-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered