MEDICARE: RENE MENDIETA

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	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1902136112
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	RENE MENDIETA

Provider Business Mailing Address
First Line	:	8850 AVALON BLVD
Second Line	:	12
City	:	LOS ANGELES
State	:	CA
Zip	:	90003-3575
Country	:	US
Telephone Number	:	323-704-6260
Fax Number	:

Provider Business Practice Location Address
First Line	:	2677 ZOE AVE
Second Line	:	303
City	:	HUNTINGTON PARK
State	:	CA
Zip	:	90255-4195
Country	:	US
Telephone Number	:	323-312-0640
Fax Number	:

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

Provider Enumeration Date	:	01/11/2010
Last Update Date	:	01/11/2010

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