1457491441 NPI number — RICO VINCENTE. I. MENDOZA,MD,PA

Table of content: (NPI 1457491441)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1457491441 NPI number — RICO VINCENTE. I. MENDOZA,MD,PA

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
RICO VINCENTE. I. MENDOZA,MD,PA
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:
1457491441
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
12/19/2012
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 4276
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SPARTANBURG
Provider Business Mailing Address State Name:
SC
Provider Business Mailing Address Postal Code:
29305-4276
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
864-582-6858
Provider Business Mailing Address Fax Number:
864-585-0999

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2030 NORTH CHURCH PLACE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SPARTANBURG
Provider Business Practice Location Address State Name:
SC
Provider Business Practice Location Address Postal Code:
29303-2706
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
864-582-6858
Provider Business Practice Location Address Fax Number:
864-585-0999
Provider Enumeration Date:
02/07/2007

Additional Information

Authorized Official

Authorized Official Last Name:
BROWN
Authorized Official First Name:
DARLA
Authorized Official Middle Name:
M
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
864-582-6858

Provider Taxonomy Codes

  • Taxonomy code: 207RP1001X , with the licence number:  23156 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RS0012X , with the licence number: 23156 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207R00000X , with the licence number: 23156 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 207RC0200X , with the licence number: 23156 , registered in the state of SC ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 231564 , issued by the state of ( SC ) . This identifiers is of the category "MEDICAID".
  • Identifier: DF9437 . This is a "RAILROAD MEDICARE" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".
  • Identifier: 8688 . This is a "MBPG'S" identifier , issued by the state of ( SC ) . This identifiers is of the category "OTHER".




Copyright © 2007-2025 www.npivalidator.com