Healthcare Provider Details

I. General information

NPI: 1154990729
Provider Name (Legal Business Name): ALDRIN JAN REYES MENDOZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/18/2021
Last Update Date: 01/16/2025
Certification Date: 01/13/2025
Deactivation Date: 09/08/2023
Reactivation Date: 01/08/2025

III. Provider practice location address

4211 AVALON BLVD
LOS ANGELES CA
90011-5622
US

IV. Provider business mailing address

4211 AVALON BLVD, LOS ANGELES CA 90011
LOS ANGELES CA
90011
US

V. Phone/Fax

Practice location:
  • Phone: 323-233-0425
  • Fax:
Mailing address:
  • Phone: 323-233-0425
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code104100000X
TaxonomySocial Worker
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code103K00000X
TaxonomyBehavior Analyst
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: