1962471078 NPI number — MR. JOSE MANUEL MENDOZA NURSE PRACTITIONER

Table of content: MR. JOSE MANUEL MENDOZA NURSE PRACTITIONER (NPI 1962471078)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1962471078 NPI number — MR. JOSE MANUEL MENDOZA NURSE PRACTITIONER

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDOZA
Provider First Name:
JOSE
Provider Middle Name:
MANUEL
Provider Name Prefix Text:
MR.
Provider Name Suffix Text:
Provider Credential Text:
NURSE PRACTITIONER
Provider Gender Code:
M

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1962471078
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/16/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1040 FLYNN RD
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
CAMARILLO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93012-5092
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-673-3930
Provider Business Mailing Address Fax Number:
805-659-3217

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
355 CENTRAL AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
FILLMORE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93015-1920
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-524-4926
Provider Business Practice Location Address Fax Number:
805-524-4137
Provider Enumeration Date:
03/14/2006

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X , with the licence number:  11411 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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