Healthcare Provider Details

I. General information

NPI: 1063345304
Provider Name (Legal Business Name): LUIS KEVIN MENDEZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/05/2026
Last Update Date: 06/05/2026
Certification Date: 06/05/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

810 JASMINE ST
OMAK WA
98841-9578
US

IV. Provider business mailing address

PO BOX 793
OMAK WA
98841-0793
US

V. Phone/Fax

Practice location:
  • Phone: 509-826-1760
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberP1.70123133
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: