Healthcare Provider Details

I. General information

NPI: 1710275441
Provider Name (Legal Business Name): MANUEL MENDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/15/2011
Last Update Date: 07/15/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

22218 CLYDE AVE
SAUK VILLAGE IL
60411-5058
US

IV. Provider business mailing address

22218 CLYDE AVE
SAUK VILLAGE IL
60411-5058
US

V. Phone/Fax

Practice location:
  • Phone: 708-757-6790
  • Fax:
Mailing address:
  • Phone: 708-757-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: