Healthcare Provider Details

I. General information

NPI: 1730675984
Provider Name (Legal Business Name): CINTHIA S MENDOZA MEDINA
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/10/2018
Last Update Date: 10/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2814 WOODCLIFF CIR SE
GRAND RAPIDS MI
49506
US

IV. Provider business mailing address

727 PLASMAN AVE
HOLLAND MI
49423-7221
US

V. Phone/Fax

Practice location:
  • Phone: 855-832-6727
  • Fax:
Mailing address:
  • Phone: 616-510-7277
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberM355116778172
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License NumberM355116778172
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: