Provider Demographics
NPI:1730846346
Name:MEDINA, MANUELA MARINA
Entity type:Individual
Prefix:
First Name:MANUELA
Middle Name:MARINA
Last Name:MEDINA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:525 TECHNOLOGY CT STE 105
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-2181
Mailing Address - Country:US
Mailing Address - Phone:951-686-8500
Mailing Address - Fax:
Practice Address - Street 1:525 TECHNOLOGY CT STE 105
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2181
Practice Address - Country:US
Practice Address - Phone:951-686-8500
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-11-18
Last Update Date:2023-12-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 172V00000X
CA175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist
No171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker