Basic Information
| Provider Information | |||||||||
| NPI: | 1720729494 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MEKDARA | ||||||||
| FirstName: | RANDY | ||||||||
| MiddleName: | |||||||||
| NamePrefix: | MR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 5010 GOLDEN WEST AVE | ||||||||
| Address2: | |||||||||
| City: | TEMPLE CITY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 917803934 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6262465286 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 902 S MYRTLE AVE | ||||||||
| Address2: | |||||||||
| City: | MONROVIA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 910163427 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6263573258 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 04/05/2022 | ||||||||
| LastUpdateDate: | 05/05/2022 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 05/05/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 101YP2500X | APCC10859 | CA | Y | Behavioral Health & Social Service Providers | Counselor | Professional | 101YM0800X | APCC10859 | CA | N | Behavioral Health & Social Service Providers | Counselor | Mental Health |
No ID Information.