Provider Demographics
NPI:1760106611
Name:MENDIBLES, REYNALDO JR
Entity Type:Individual
Prefix:
First Name:REYNALDO
Middle Name:
Last Name:MENDIBLES
Suffix:JR
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 1:7475 E RIO VISTA CIR
Mailing Address - Street 2:
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85715-3547
Mailing Address - Country:US
Mailing Address - Phone:520-304-1502
Mailing Address - Fax:
Practice Address - Street 1:7475 E RIO VISTA CIR
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85715-3547
Practice Address - Country:US
Practice Address - Phone:520-304-1502
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-03
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL12291H3104A0630X, 310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility
No3104A0630XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Behavioral Disturbances