Basic Information
| Provider Information | |||||||||
| NPI: | 1992434724 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | MAXIM HEALTHCARE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3111 CAMINO DEL RIO N STE 200 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921085722 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6192093696 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2401 SEASIDE ST APT 308 | ||||||||
| Address2: | |||||||||
| City: | SAN DIEGO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 921071478 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6198308525 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/07/2022 | ||||||||
| LastUpdateDate: | 06/07/2022 | ||||||||
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| AuthorizedOfficialLastName: | MEZA | ||||||||
| AuthorizedOfficialFirstName: | MELISSA | ||||||||
| AuthorizedOfficialMiddleName: | ZUYEIRI | ||||||||
| AuthorizedOfficialTitleorPosition: | LVN | ||||||||
| AuthorizedOfficialTelephone: | 6198308525 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
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| NPICertificationDate: | 06/07/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | Y | 193400000X SINGLE SPECIALTY GROUP | Nursing Service Providers | Licensed Vocational Nurse |
ID Information
| ID | Type | State | Issuer | Description | XXX-XX-7056 | 01 | CA | MELISSA Z MEZA | OTHER | 7056 | 01 | CA | N/A | OTHER |