Provider Demographics
NPI:1891118774
Name:MENDOZA, VIANCA
Entity Type:Individual
Prefix:
First Name:VIANCA
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17714 W DESERT LN
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-1714
Mailing Address - Country:US
Mailing Address - Phone:720-979-5919
Mailing Address - Fax:
Practice Address - Street 1:17714 W DESERT LN
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-1714
Practice Address - Country:US
Practice Address - Phone:720-979-5919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-01-28
Last Update Date:2014-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1710I1003XOther Service ProvidersMilitary Health Care ProviderIndependent Duty Medical Technicians