Healthcare Provider Details

I. General information

NPI: 1750082178
Provider Name (Legal Business Name): MARINELLA MENDOZA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/13/2023
Last Update Date: 03/13/2023
Certification Date: 03/13/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 LOMALAND DR
SAN DIEGO CA
92106-2810
US

IV. Provider business mailing address

149 S AVENUE 54 APT 3
LOS ANGELES CA
90042-4556
US

V. Phone/Fax

Practice location:
  • Phone: 619-849-2200
  • Fax:
Mailing address:
  • Phone: 213-453-2557
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2081S0010X
TaxonomySports Medicine (Physical Medicine & Rehabilitation) Physician
License Number501C3
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: