Basic Information
| Provider Information | |||||||||
| NPI: | 1205553575 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEANS | ||||||||
| FirstName: | DEMETRIOUS | ||||||||
| MiddleName: | MARIN | ||||||||
| NamePrefix: | |||||||||
| NameSuffix: | SR. | ||||||||
| Credential: | NONE | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | |||||||||
| OtherFirstName: | |||||||||
| OtherMiddleName: | |||||||||
| OtherNamePrefix: | |||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | |||||||||
| OtherLastNameType: | |||||||||
| Mailing Information | |||||||||
| Address1: | 209 PLAZA DRIVE | ||||||||
| Address2: | 100 | ||||||||
| City: | ROCKLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889222843 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Practice Location | |||||||||
| Address1: | 209 PLAZA DRIVE | ||||||||
| Address2: | 100 | ||||||||
| City: | ROCKLIN | ||||||||
| State: | CA | ||||||||
| PostalCode: | 95765 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8889222843 | ||||||||
| FaxNumber: | 8555682494 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/26/2022 | ||||||||
| LastUpdateDate: | 10/26/2022 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
| NPIDeactivationDate: | |||||||||
| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | M | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | |||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | 10/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.