Healthcare Provider Details

I. General information

NPI: 1063874337
Provider Name (Legal Business Name): MISSION UROLOGY, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/24/2016
Last Update Date: 06/24/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 BROCKTON AVE SUITE 301
RIVERSIDE CA
92501-4027
US

IV. Provider business mailing address

PO BOX 7270
MORENO VALLEY CA
92552-7270
US

V. Phone/Fax

Practice location:
  • Phone: 951-276-4505
  • Fax: 951-276-4517
Mailing address:
  • Phone: 951-656-1500
  • Fax: 951-656-1510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code208800000X
TaxonomyUrology Physician
License Number
License Number State

VIII. Authorized Official

Name: JO-ANN MENDOZA
Title or Position: PRESIDENT
Credential: MD
Phone: 951-276-4505