Provider Demographics
NPI:1578107140
Name:MENDOZA, ERNESTO DANIEL
Entity Type:Individual
Prefix:MR
First Name:ERNESTO
Middle Name:DANIEL
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 1:11572 SANTA CRUZ ST
Mailing Address - Street 2:
Mailing Address - City:STANTON
Mailing Address - State:CA
Mailing Address - Zip Code:90680-3542
Mailing Address - Country:US
Mailing Address - Phone:714-718-3422
Mailing Address - Fax:
Practice Address - Street 1:11572 SANTA CRUZ ST
Practice Address - Street 2:
Practice Address - City:STANTON
Practice Address - State:CA
Practice Address - Zip Code:90680-3542
Practice Address - Country:US
Practice Address - Phone:714-718-3422
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-11-06
Last Update Date:2019-11-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD6017950343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)