Provider Demographics
NPI:1891208237
Name:LASTRE MENDOZA, NOEL E
Entity Type:Individual
Prefix:
First Name:NOEL
Middle Name:E
Last Name:LASTRE 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 1:9064 COLLINS AVE APT 9
Mailing Address - Street 2:
Mailing Address - City:SURFSIDE
Mailing Address - State:FL
Mailing Address - Zip Code:33154-3253
Mailing Address - Country:US
Mailing Address - Phone:786-622-9776
Mailing Address - Fax:
Practice Address - Street 1:9064 COLLINS AVE APT 9
Practice Address - Street 2:
Practice Address - City:SURFSIDE
Practice Address - State:FL
Practice Address - Zip Code:33154-3253
Practice Address - Country:US
Practice Address - Phone:786-622-9776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-08
Last Update Date:2017-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician