=====================================================
General NPI Number Information
=====================================================
NPI Number | 1821572041
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MR. JONATTAN MENDEZ I
-----------------------------------------------------
Gender | Male
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/24/2018
-----------------------------------------------------
Last Update Date | 09/24/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 170 FARNUM DR
-----------------------------------------------------
City | HOLYOKE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01040-2808
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-210-9760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 95 FRANK B MURRAY ST
-----------------------------------------------------
City | SPRINGFIELD
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 01103-1106
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 413-210-9760
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 390200000X
-----------------------------------------------------
Taxonomy Name | Student in an Organized Health Care Education/Training Program
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------