Healthcare Provider Details

I. General information

NPI: 1609056514
Provider Name (Legal Business Name): ENRIQUE MENDOZA LVN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/08/2007
Last Update Date: 04/13/2009
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7590 FRAZER DR
RIVERSIDE CA
92509-5332
US

IV. Provider business mailing address

7590 FRAZER DR
RIVERSIDE CA
92509-5332
US

V. Phone/Fax

Practice location:
  • Phone: 951-727-0675
  • Fax: 951-727-0675
Mailing address:
  • Phone: 951-727-0675
  • Fax: 951-205-8601

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVN217872
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: