Provider Demographics
NPI:1588130900
Name:MENDOZA, ILIAN OMAR
Entity type:Individual
Prefix:
First Name:ILIAN
Middle Name:OMAR
Last Name:MENDOZA
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 1:1079 GAVIOTA AVE
Mailing Address - Street 2:
Mailing Address - City:LONG BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:90813-3811
Mailing Address - Country:US
Mailing Address - Phone:562-708-3651
Mailing Address - Fax:
Practice Address - Street 1:9333 IMPERIAL HWY
Practice Address - Street 2:
Practice Address - City:DOWNEY
Practice Address - State:CA
Practice Address - Zip Code:90242-2812
Practice Address - Country:US
Practice Address - Phone:800-823-4040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-24
Last Update Date:2018-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA250672278P3900X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2278P3900XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRespiratory Therapist, CertifiedNeonatal/Pediatrics