Healthcare Provider Details

I. General information

NPI: 1831649870
Provider Name (Legal Business Name): TYLER NICHOLAS MENDOZA RT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11262 SEGA LN
FONTANA CA
92337-6820
US

IV. Provider business mailing address

11262 SEGA LN
FONTANA CA
92337-6820
US

V. Phone/Fax

Practice location:
  • Phone: 714-477-3964
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number38508
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: