Provider Demographics
NPI:1417268442
Name:MENDOZA, PABLO ALBERTO
Entity Type:Individual
Prefix:
First Name:PABLO
Middle Name:ALBERTO
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 1:2349 MYRTLE RD
Mailing Address - Street 2:
Mailing Address - City:IMPERIAL
Mailing Address - State:CA
Mailing Address - Zip Code:92251-9715
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2349 MYRTLE RD
Practice Address - Street 2:
Practice Address - City:IMPERIAL
Practice Address - State:CA
Practice Address - Zip Code:92251-9715
Practice Address - Country:US
Practice Address - Phone:760-234-6101
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-06-24
Last Update Date:2010-06-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA8924225200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225200000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapy Assistant