Healthcare Provider Details

I. General information

NPI: 1336645928
Provider Name (Legal Business Name): THEODORE BULACAN MENDOZA III FNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/03/2018
Last Update Date: 04/03/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6407 S COOPER ST STE 117
ARLINGTON TX
76001-5813
US

IV. Provider business mailing address

7328 LAGUNA
GRAND PRAIRIE TX
75054-0139
US

V. Phone/Fax

Practice location:
  • Phone: 817-472-7601
  • Fax:
Mailing address:
  • Phone: 972-898-8933
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP136094
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: