Healthcare Provider Details

I. General information

NPI: 1134372469
Provider Name (Legal Business Name): LILIA MENDIVIL BC, RN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/30/2008
Last Update Date: 10/28/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

425 N DATE ST
ESCONDIDO CA
92025-3413
US

IV. Provider business mailing address

9894 GENESEE AVENUE
LA JOLLA CA
92037
US

V. Phone/Fax

Practice location:
  • Phone: 760-520-8372
  • Fax:
Mailing address:
  • Phone: 858-231-8574
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License NumberRN444766
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: