1477064756 NPI number — MRS. BRENDA REYNA MENDEZ 9489 - R

Table of content: MRS. BRENDA REYNA MENDEZ 9489 - R (NPI 1477064756)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1477064756 NPI number — MRS. BRENDA REYNA MENDEZ 9489 - R

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MENDEZ
Provider First Name:
BRENDA
Provider Middle Name:
REYNA
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
9489 - R
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
MENDEZ
Provider Other First Name:
BRENDA
Provider Other Middle Name:
REYNA
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1477064756
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
10/13/2017
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2180 JOHNSON AVE
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN LUIS OBISPO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
93401-4558
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
805-473-7080
Provider Business Mailing Address Fax Number:
805-473-7188

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2180 JOHNSON AVE
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN LUIS OBISPO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
93401-4558
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
805-473-7080
Provider Business Practice Location Address Fax Number:
805-473-7188
Provider Enumeration Date:
10/13/2017

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: 101YP2500X , with the licence number:  9489-R , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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





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