Provider Demographics
NPI:1457491441
Name:RICO VINCENTE. I. MENDOZA,MD,PA
Entity Type:Organization
Organization Name:RICO VINCENTE. I. MENDOZA,MD,PA
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MS
Authorized Official - First Name:DARLA
Authorized Official - Middle Name:M
Authorized Official - Last Name:BROWN
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:864-582-6858
Mailing Address - Street 1:PO BOX 4276
Mailing Address - Street 2:
Mailing Address - City:SPARTANBURG
Mailing Address - State:SC
Mailing Address - Zip Code:29305-4276
Mailing Address - Country:US
Mailing Address - Phone:864-582-6858
Mailing Address - Fax:864-585-0999
Practice Address - Street 1:2030 NORTH CHURCH PLACE
Practice Address - Street 2:
Practice Address - City:SPARTANBURG
Practice Address - State:SC
Practice Address - Zip Code:29303-2706
Practice Address - Country:US
Practice Address - Phone:864-582-6858
Practice Address - Fax:864-585-0999
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-07
Last Update Date:2012-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC23156207R00000X, 207RC0200X, 207RP1001X, 207RS0012X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RC0200XAllopathic & Osteopathic PhysiciansInternal MedicineCritical Care MedicineGroup - Multi-Specialty
No207R00000XAllopathic & Osteopathic PhysiciansInternal MedicineGroup - Multi-Specialty
No207RP1001XAllopathic & Osteopathic PhysiciansInternal MedicinePulmonary DiseaseGroup - Multi-Specialty
No207RS0012XAllopathic & Osteopathic PhysiciansInternal MedicineSleep MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
SC231564Medicaid
SCDF9437OtherRAILROAD MEDICARE
SC8688OtherMBPG'S
SCG14240Medicare UPIN
SCDF9437OtherRAILROAD MEDICARE