Healthcare Provider Details

I. General information

NPI: 1083452940
Provider Name (Legal Business Name): OMAR MENDOZA CHAVEZ RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/16/2024
Last Update Date: 07/16/2024
Certification Date: 07/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

339 PAJARO ST
SALINAS CA
93901-3400
US

IV. Provider business mailing address

17 PERA DR
WATSONVILLE CA
95076-3024
US

V. Phone/Fax

Practice location:
  • Phone: 831-800-7530
  • Fax:
Mailing address:
  • Phone: 831-288-4831
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95379295
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: