Healthcare Provider Details

I. General information

NPI: 1124893995
Provider Name (Legal Business Name): RENATO MENDOZA MANZANO RN, CNS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2023
Last Update Date: 11/21/2023
Certification Date: 11/20/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

IV. Provider business mailing address

200 W ARBOR DR
SAN DIEGO CA
92103-9000
US

V. Phone/Fax

Practice location:
  • Phone: 619-543-8243
  • Fax:
Mailing address:
  • Phone: 619-543-4689
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code364SA2200X
TaxonomyAdult Health Clinical Nurse Specialist
License Number3193
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: