Healthcare Provider Details

I. General information

NPI: 1609737782
Provider Name (Legal Business Name): SHANNON MENDOZA
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/19/2025
Last Update Date: 11/19/2025
Certification Date: 11/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1317 W FOOTHILL BLVD STE 1330
UPLAND CA
91786-3676
US

IV. Provider business mailing address

1317 W FOOTHILL BLVD STE 1330
UPLAND CA
91786-3676
US

V. Phone/Fax

Practice location:
  • Phone: 800-741-1164
  • Fax:
Mailing address:
  • Phone: 800-741-1164
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225800000X
TaxonomyRecreation Therapist
License Number69194
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: