Provider Demographics
NPI:1629386594
Name:HARRY S MENCO MD , INC
Entity Type:Organization
Organization Name:HARRY S MENCO MD , INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL ASSISTANT
Authorized Official - Prefix:MS
Authorized Official - First Name:NICOLE
Authorized Official - Middle Name:
Authorized Official - Last Name:MCCRACKEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:805-496-2949
Mailing Address - Street 1:227 W JANSS RD
Mailing Address - Street 2:SUITE 310
Mailing Address - City:THOUSAND OAKS
Mailing Address - State:CA
Mailing Address - Zip Code:91360-1848
Mailing Address - Country:US
Mailing Address - Phone:805-496-2949
Mailing Address - Fax:805-496-1844
Practice Address - Street 1:227 W JANSS RD
Practice Address - Street 2:SUITE 310
Practice Address - City:THOUSAND OAKS
Practice Address - State:CA
Practice Address - Zip Code:91360-1848
Practice Address - Country:US
Practice Address - Phone:805-496-2949
Practice Address - Fax:805-496-1844
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-09-14
Last Update Date:2010-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAA41745305R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes305R00000XManaged Care OrganizationsPreferred Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAA41745OtherPTAN
CAA41745OtherPTAN