Provider Demographics
NPI:1154621720
Name:JUAN ANTONIO MENDOZA
Entity type:Organization
Organization Name:JUAN ANTONIO MENDOZA
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:
Authorized Official - Last Name:PRATER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:619-285-5040
Mailing Address - Street 1:6190 FAIRMOUNT AVE
Mailing Address - Street 2:SUITE A
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92120-3428
Mailing Address - Country:US
Mailing Address - Phone:619-285-5040
Mailing Address - Fax:619-285-5045
Practice Address - Street 1:6190 FAIRMOUNT AVE
Practice Address - Street 2:SUITE A
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92120-3428
Practice Address - Country:US
Practice Address - Phone:619-285-5040
Practice Address - Fax:619-285-5045
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-10-28
Last Update Date:2011-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0900XAmbulatory Health Care FacilitiesClinic/CenterAmputee
No261Q00000XAmbulatory Health Care FacilitiesClinic/Center
Provider Identifiers
StateIdentifier IDID TypeIssuer
6477590001Medicare NSC