MEDICARE: ROY MENDIZABAL

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	225100000X	Physical Therapist		GA

General Provider Information

NPI Number	:	1639917719
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ROY MENDIZABAL

Provider Business Mailing Address
First Line	:	790 REMINGTON BLVD
Second Line	:
City	:	BOLINGBROOK
State	:	IL
Zip	:	60440-4909
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	1343 W WALNUT AVE
Second Line	:
City	:	DALTON
State	:	GA
Zip	:	30720-3857
Country	:	US
Telephone Number	:	706-913-8201
Fax Number	:	706-459-3646

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

Provider Enumeration Date	:	07/15/2024
Last Update Date	:	07/15/2024

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Directions to “ ROY MENDIZABAL ” Practice Location

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