Healthcare Provider Details

I. General information

NPI: 1477992667
Provider Name (Legal Business Name): JUAN C MENDOZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/20/2013
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 GOODRICH BLVD
COMMERCE CA
90022-5103
US

IV. Provider business mailing address

1000 GOODRICH BLVD
COMMERCE CA
90022-5103
US

V. Phone/Fax

Practice location:
  • Phone: 323-832-9795
  • Fax:
Mailing address:
  • Phone: 323-832-9795
  • Fax: 818-987-3138

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106H00000X
TaxonomyMarriage & Family Therapist
License Number116475
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: