Healthcare Provider Details

I. General information

NPI: 1881694487
Provider Name (Legal Business Name): JAIME MENDOZA LOTR,CHT
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/26/2005
Last Update Date: 07/15/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2727 KALISTE SALOOM RD SUITE 101
LAFAYETTE LA
70508-7151
US

IV. Provider business mailing address

PO BOX 52522
LAFAYETTE LA
70505-2522
US

V. Phone/Fax

Practice location:
  • Phone: 337-981-4053
  • Fax: 337-981-2448
Mailing address:
  • Phone: 337-981-4053
  • Fax: 337-981-2448

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225X00000X
TaxonomyOccupational Therapist
License NumberZ12097
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: