MEDICARE: JUAN MENDOZA

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	104100000X	Social Worker
2	225C00000X	Rehabilitation Counselor

General Provider Information

NPI Number	:	1457820193
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JUAN MENDOZA

Provider Business Mailing Address
First Line	:	1905 SANTA PAULA DR APT C
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-2422
Country	:	US
Telephone Number	:	702-370-8625
Fax Number	:

Provider Business Practice Location Address
First Line	:	1905 SANTA PAULA DR APT C
Second Line	:
City	:	LAS VEGAS
State	:	NV
Zip	:	89104-2422
Country	:	US
Telephone Number	:	702-370-8625
Fax Number	:

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

Provider Enumeration Date	:	11/23/2018
Last Update Date	:	01/09/2021

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Directions to “ JUAN MENDOZA ” Practice Location

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