Healthcare Provider Details

I. General information

NPI: 1942977574
Provider Name (Legal Business Name): LUIS FERNANDO PEREZ MENDOZA RADT II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/23/2021
Last Update Date: 08/23/2021
Certification Date: 08/23/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1218 E COMPTON BLVD
COMPTON CA
90221-3310
US

IV. Provider business mailing address

1218 E COMPTON BLVD
COMPTON CA
90221-3310
US

V. Phone/Fax

Practice location:
  • Phone: 323-399-6237
  • Fax:
Mailing address:
  • Phone: 310-608-1505
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License NumberR1436170621
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: