Healthcare Provider Details

I. General information

NPI: 1013240589
Provider Name (Legal Business Name): MARK MENDES OT
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/15/2009
Last Update Date: 09/15/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1100 W MORTON AVE
PORTERVILLE CA
93257-1947
US

IV. Provider business mailing address

1301 E BIDWELL ST SUITE 201
FOLSOM CA
95630-3565
US

V. Phone/Fax

Practice location:
  • Phone: 559-782-1509
  • Fax: 559-781-5220
Mailing address:
  • Phone: 916-983-5915
  • Fax: 916-983-5925

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License Number4478
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: