1073522413 NPI number — VERONICA R MENDEZ

Table of content: (NPI 1073522413)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1073522413 NPI number — VERONICA R MENDEZ

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
VERONICA R MENDEZ
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
MIRACLE HEALTH PRODUCTS
Provider Other Organization Name Type Code:
3
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:
1073522413
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
06/19/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
660 S W MILITARY DRIVE
Provider Second Line Business Mailing Address:
SUITE V
Provider Business Mailing Address City Name:
SAN ANTONIO
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
78221-1686
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
210-927-2006
Provider Business Mailing Address Fax Number:
210-927-2051

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
660 SW MILITARY DR
Provider Second Line Business Practice Location Address:
SUITE V
Provider Business Practice Location Address City Name:
SAN ANTONIO
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
78221-1645
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
210-927-2006
Provider Business Practice Location Address Fax Number:
210-927-2051
Provider Enumeration Date:
08/05/2006

Additional Information

Authorized Official

Authorized Official Last Name:
MENDEZ
Authorized Official First Name:
VERONICA
Authorized Official Middle Name:
R
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
210-927-2006

Provider Taxonomy Codes

  • Taxonomy code: 332B00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 169698102 , issued by the state of ( TX ) . This identifiers is of the category "MEDICAID".




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