Provider Demographics
NPI:1609441302
Name:MENDOZA-ROGUE, ELVIS (LMBT)
Entity Type:Individual
Prefix:
First Name:ELVIS
Middle Name:
Last Name:MENDOZA-ROGUE
Suffix:
Gender:M
Credentials:LMBT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1716 WILLOW RD
Mailing Address - Street 2:
Mailing Address - City:GREENSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27401-3921
Mailing Address - Country:US
Mailing Address - Phone:336-212-7614
Mailing Address - Fax:
Practice Address - Street 1:1716 WILLOW RD
Practice Address - Street 2:
Practice Address - City:GREENSBORO
Practice Address - State:NC
Practice Address - Zip Code:27401-3921
Practice Address - Country:US
Practice Address - Phone:336-212-7614
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-05-25
Last Update Date:2021-05-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC18352225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist