Healthcare Provider Details

I. General information

NPI: 1134542418
Provider Name (Legal Business Name): BENITO MENDOZA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/22/2014
Last Update Date: 01/22/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7232 CANBY AVE STE 456
RESEDA CA
91335-3006
US

IV. Provider business mailing address

7232 CANBY AVE STE 456
RESEDA CA
91335-3006
US

V. Phone/Fax

Practice location:
  • Phone: 818-705-5561
  • Fax:
Mailing address:
  • Phone: 818-705-5561
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: