1366659161 NPI number — SELENE MENDOZA CNP

Table of content: SELENE MENDOZA CNP (NPI 1366659161)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1366659161 NPI number — SELENE MENDOZA CNP

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDOZA
Provider First Name:
SELENE
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CNP
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:
1366659161
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/31/2016
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
1161 MALL DR STE C
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAS CRUCES
Provider Business Mailing Address State Name:
NM
Provider Business Mailing Address Postal Code:
88011-8193
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
575-522-2330
Provider Business Mailing Address Fax Number:
575-522-2344

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1161 MALL DR
Provider Second Line Business Practice Location Address:
STE. C
Provider Business Practice Location Address City Name:
LAS CRUCES
Provider Business Practice Location Address State Name:
NM
Provider Business Practice Location Address Postal Code:
88011-8193
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
575-522-2330
Provider Business Practice Location Address Fax Number:
575-522-2344
Provider Enumeration Date:
05/17/2007

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: 163WP0808X , with the licence number:  CNP01102 , registered in the state of NM ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 45401837 , issued by the state of ( NM ) . This identifiers is of the category "MEDICAID".




Copyright © 2007-2025 www.npivalidator.com