Provider Demographics
NPI:1417599002
Name:MENDOZA, TOMAS FEDERICO (LAC)
Entity Type:Individual
Prefix:
First Name:TOMAS
Middle Name:FEDERICO
Last Name:MENDOZA
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:FRED
Other - Middle Name:THOMAS
Other - Last Name:MENDOZA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LAC, RN
Mailing Address - Street 1:PO BOX 1004
Mailing Address - Street 2:
Mailing Address - City:SAN LUIS OBISPO
Mailing Address - State:CA
Mailing Address - Zip Code:93406-1004
Mailing Address - Country:US
Mailing Address - Phone:760-201-7768
Mailing Address - Fax:
Practice Address - Street 1:1407 GARDEN ST
Practice Address - Street 2:
Practice Address - City:SAN LUIS OBISPO
Practice Address - State:CA
Practice Address - Zip Code:93401-3917
Practice Address - Country:US
Practice Address - Phone:805-242-1060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-10-15
Last Update Date:2019-10-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA10731171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171100000XOther Service ProvidersAcupuncturistGroup - Multi-Specialty