1033756143 NPI number — MARIBEL ACIDERA MENDOZA

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1033756143 NPI number — MARIBEL ACIDERA MENDOZA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDOZA
Provider First Name:
MARIBEL
Provider Middle Name:
ACIDERA
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:
F

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:
1033756143
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
12/09/2019
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
94-283 KAHUANANI STREET B
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
WAIPAHU
Provider Business Mailing Address State Name:
HI
Provider Business Mailing Address Postal Code:
96797-3528
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
808-364-2559
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1050 QUEEN ST STE 100
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
HONOLULU
Provider Business Practice Location Address State Name:
HI
Provider Business Practice Location Address Postal Code:
96814-4130
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
808-451-2220
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
12/09/2019

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: 103K00000X , registered in the state of HI ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 0000287473 , issued by the state of ( HI ) . This identifiers is of the category "MEDICAID".




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