=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366304412
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | RYAN DERRICK MENDEZ
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 11/26/2025
-----------------------------------------------------
Last Update Date | 11/26/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 5804 BURT RD APT A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29206-6317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-379-9502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 5804 BURT RD APT A
-----------------------------------------------------
City | COLUMBIA
-----------------------------------------------------
State | SC
-----------------------------------------------------
Zip | 29206-6317
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 786-379-9502
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 246Z00000X
-----------------------------------------------------
Taxonomy Name | Other Specialist/Technologist
-----------------------------------------------------
License Number | M532-724-95-413-0
-----------------------------------------------------
License Number State | SC
-----------------------------------------------------