=====================================================
General NPI Number Information
=====================================================
NPI Number | 1336645928
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | THEODORE BULACAN MENDOZA III FNP-BC
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/03/2018
-----------------------------------------------------
Last Update Date | 04/03/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6407 S COOPER ST STE 117
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76001-5813
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 817-472-7601
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 7328 LAGUNA
-----------------------------------------------------
City | GRAND PRAIRIE
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75054-0139
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 972-898-8933
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number | AP136094
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------