MEDICARE: JONATHAN MENDRES LAT,ATC

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	AL4573	FL

General Provider Information

NPI Number	:	1619644465
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JONATHAN MENDRES LAT,ATC

Provider Business Mailing Address
First Line	:	13815 CADEN GLEN DR
Second Line	:
City	:	HUDSON
State	:	FL
Zip	:	34669-5021
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5355 SCHOOL RD
Second Line	:
City	:	NEW PORT RICHEY
State	:	FL
Zip	:	34652-4322
Country	:	US
Telephone Number	:	727-774-3300
Fax Number	:

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

Provider Enumeration Date	:	08/27/2021
Last Update Date	:	08/27/2021

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