MEDICARE: MR. ADAM EZEQUIEL MENDEZ

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2000007437	CA

General Provider Information

NPI Number	:	1275427676
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. ADAM EZEQUIEL MENDEZ

Provider Business Mailing Address
First Line	:	2799 EXPLORADOR
Second Line	:
City	:	GRAND PRAIRIE
State	:	TX
Zip	:	75054-5544
Country	:	US
Telephone Number	:	408-854-4787
Fax Number	:

Provider Business Practice Location Address
First Line	:	43880 HARPER LAKE RD
Second Line	:
City	:	HINKLEY
State	:	CA
Zip	:	92347-9541
Country	:	US
Telephone Number	:	408-854-4787
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/09/2025
Last Update Date	:	06/09/2025

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