Provider Demographics
NPI:1518685429
Name:MENDOZA PEREZ, LUIS
Entity Type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:MENDOZA PEREZ
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 1:5000 SW 134TH AVE
Mailing Address - Street 2:
Mailing Address - City:MIRAMAR
Mailing Address - State:FL
Mailing Address - Zip Code:33027-5511
Mailing Address - Country:US
Mailing Address - Phone:786-493-7976
Mailing Address - Fax:
Practice Address - Street 1:5000 SW 134TH AVE
Practice Address - Street 2:
Practice Address - City:MIRAMAR
Practice Address - State:FL
Practice Address - Zip Code:33027-5511
Practice Address - Country:US
Practice Address - Phone:786-493-7976
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-16
Last Update Date:2022-08-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB812382106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician