Provider Demographics
NPI:1538745849
Name:MEDINA GARCIA, JUAN
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:
Last Name:MEDINA GARCIA
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3123 INDEPENDENCE DR
Mailing Address - Street 2:
Mailing Address - City:LIVERMORE
Mailing Address - State:CA
Mailing Address - Zip Code:94551-7595
Mailing Address - Country:US
Mailing Address - Phone:925-999-4119
Mailing Address - Fax:
Practice Address - Street 1:1111 W TOKAY ST STE AC
Practice Address - Street 2:
Practice Address - City:LODI
Practice Address - State:CA
Practice Address - Zip Code:95240-3965
Practice Address - Country:US
Practice Address - Phone:925-999-4119
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-03-18
Last Update Date:2024-01-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
No106S00000XBehavioral Health & Social Service ProvidersBehavior Technician