1295908101 NPI number — DR. MENDOZA'S PEDIATRIC AND ADOLSCENT

Table of content: (NPI 1295908101)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1295908101 NPI number — DR. MENDOZA'S PEDIATRIC AND ADOLSCENT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
DR. MENDOZA'S PEDIATRIC AND ADOLSCENT
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:
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:
1295908101
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
07/10/2014
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 790
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JACKSON
Provider Business Mailing Address State Name:
KY
Provider Business Mailing Address Postal Code:
41339-0790
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
606-693-4800
Provider Business Mailing Address Fax Number:
606-693-4825

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
424 JETT DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JACKSON
Provider Business Practice Location Address State Name:
KY
Provider Business Practice Location Address Postal Code:
41339-9621
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
606-693-4800
Provider Business Practice Location Address Fax Number:
606-693-4825
Provider Enumeration Date:
04/11/2008

Additional Information

Authorized Official

Authorized Official Last Name:
MENDOZA
Authorized Official First Name:
EDGAR
Authorized Official Middle Name:
ALLEN
Authorized Official Title or Position:
OWNER
Authorized Official Telephone Number:
606-693-4800

Provider Taxonomy Codes

  • Taxonomy code: 2080A0000X , with the licence number:  33465 , registered in the state of KY ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 31000979 , issued by the state of ( KY ) . This identifiers is of the category "MEDICAID".




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