Healthcare Provider Details

I. General information

NPI: 1710320585
Provider Name (Legal Business Name): EDWARD FLOYD MENCHACA B.A.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/11/2013
Last Update Date: 05/16/2025
Certification Date: 05/16/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1904 RICHLAND AVE BLDG F
CERES CA
95307-4562
US

IV. Provider business mailing address

1904 RICHLAND AVE BLDG F
CERES CA
95307-4562
US

V. Phone/Fax

Practice location:
  • Phone: 209-525-5043
  • Fax: 209-541-2648
Mailing address:
  • Phone: 209-525-5043
  • Fax: 209-541-2648

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: