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General NPI Number Information
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NPI Number | 1902136112
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Entity Type | Individual
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Provider Name | RENE MENDIETA
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Gender | Male
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Dates
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Enumeration Date | 01/11/2010
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Last Update Date | 01/11/2010
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Provider Practice Location Address
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Address Line | 2677 ZOE AVE 303
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City | HUNTINGTON PARK
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State | CA
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Zip | 90255-4195
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Country | US
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Telephone | 323-312-0640
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Fax |
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Provider Business Mailing Address
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Address Line | 8850 AVALON BLVD 12
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City | LOS ANGELES
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State | CA
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Zip | 90003-3575
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Country | US
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Telephone | 323-704-6260
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 390200000X
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Taxonomy Name | Student in an Organized Health Care Education/Training Program
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License Number |
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License Number State |
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