1497209746 NPI number — MRS. LAURA MARIE WEIGAND MENDOZA PT

Table of content: MRS. LAURA MARIE WEIGAND MENDOZA PT (NPI 1497209746)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1497209746 NPI number — MRS. LAURA MARIE WEIGAND MENDOZA PT

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
WEIGAND MENDOZA
Provider First Name:
LAURA
Provider Middle Name:
MARIE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
PT
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
WEIGAND
Provider Other First Name:
LAURA
Provider Other Middle Name:
MARIE
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1497209746
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
11/01/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
6217 BOULDER LAKE AVE APT 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SAN DIEGO
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
92119-3301
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
818-568-4087
Provider Business Mailing Address Fax Number:

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
8080 DAGGET ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SAN DIEGO
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
92111-2333
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
858-395-3671
Provider Business Practice Location Address Fax Number:
Provider Enumeration Date:
08/03/2016

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: 225100000X , with the licence number:  291754 , 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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