Healthcare Provider Details

I. General information

NPI: 1730877432
Provider Name (Legal Business Name): JOB MILLER MENDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/01/2023
Last Update Date: 07/03/2023
Certification Date: 07/02/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4237 ATLANTIC AVE
LONG BEACH CA
90807-2801
US

IV. Provider business mailing address

5786 TRINIDAD WAY
BUENA PARK CA
90620-1256
US

V. Phone/Fax

Practice location:
  • Phone: 532-336-1656
  • Fax:
Mailing address:
  • Phone: 630-597-6773
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95025137
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95080477
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: