=====================================================
General NPI Number Information
=====================================================
NPI Number | 1366636961
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | ERIC MENDOZA FLORES PT
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 08/28/2007
-----------------------------------------------------
Last Update Date | 12/26/2014
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 83 FRANKLIN TPKE
-----------------------------------------------------
City | WALDWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07463-1820
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-445-1079
-----------------------------------------------------
Fax | 201-445-1315
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 83 FRANKLIN TURNPIKE
-----------------------------------------------------
City | WALDWICK
-----------------------------------------------------
State | NJ
-----------------------------------------------------
Zip | 07463
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 201-244-6932
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225100000X
-----------------------------------------------------
Taxonomy Name | Physical Therapist
-----------------------------------------------------
License Number | 40QA01159700
-----------------------------------------------------
License Number State | NJ
-----------------------------------------------------