Provider Demographics
NPI:1477338861
Name:MENDEZ, GUSTAVO BLISS
Entity type:Individual
Prefix:
First Name:GUSTAVO
Middle Name:BLISS
Last Name:MENDEZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4438 FERN CT NE
Mailing Address - Street 2:
Mailing Address - City:SALEM
Mailing Address - State:OR
Mailing Address - Zip Code:97305-2261
Mailing Address - Country:US
Mailing Address - Phone:971-719-5309
Mailing Address - Fax:
Practice Address - Street 1:1118 OAK ST SE
Practice Address - Street 2:
Practice Address - City:SALEM
Practice Address - State:OR
Practice Address - Zip Code:97301-4019
Practice Address - Country:US
Practice Address - Phone:503-585-4949
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-25
Last Update Date:2023-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator