=====================================================
General NPI Number Information
=====================================================
NPI Number | 1235098385
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | CERTIFIED CREDENTIALING, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/15/2026
-----------------------------------------------------
Last Update Date | 01/15/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6036 RIDGECREST RD APT 106
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75231-6735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-444-8357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 6036 RIDGECREST RD APT 106
-----------------------------------------------------
City | DALLAS
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75231-6735
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 214-444-8357
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | DIRECTOR OF CREDENTIALING
-----------------------------------------------------
Name | JUAN MENDEZ
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 971-469-0000
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 171W00000X
-----------------------------------------------------
Taxonomy Name | Contractor
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------