Provider Demographics
NPI:1073149944
Name:MENDEZ, RUSSELL
Entity Type:Individual
Prefix:
First Name:RUSSELL
Middle Name:
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 1:1786 KINOOLE ST
Mailing Address - Street 2:
Mailing Address - City:HILO
Mailing Address - State:HI
Mailing Address - Zip Code:96720-5245
Mailing Address - Country:US
Mailing Address - Phone:808-959-5855
Mailing Address - Fax:
Practice Address - Street 1:1786 KINOOLE ST
Practice Address - Street 2:
Practice Address - City:HILO
Practice Address - State:HI
Practice Address - Zip Code:96720-5245
Practice Address - Country:US
Practice Address - Phone:714-316-3868
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-03-23
Last Update Date:2020-03-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320800000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Mental Illness