Healthcare Provider Details

I. General information

NPI: 1760348577
Provider Name (Legal Business Name): KIMBERLY MENDIVIL
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/25/2025
Last Update Date: 06/19/2026
Certification Date: 06/19/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

473 E CARNEGIE DR
SAN BERNARDINO CA
92408
US

IV. Provider business mailing address

31445 AVENIDA JUAREZ
CATHEDRAL CITY CA
92234-3012
US

V. Phone/Fax

Practice location:
  • Phone: 760-237-8070
  • Fax:
Mailing address:
  • Phone: 760-980-4656
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number StateNULL
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: