Provider Demographics
NPI:1417785825
Name:MENDIVIL, JOSE LUIS JR
Entity type:Individual
Prefix:
First Name:JOSE
Middle Name:LUIS
Last Name:MENDIVIL
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 1:3525 PRESLEY AVE STE 12
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4453
Mailing Address - Country:US
Mailing Address - Phone:951-955-9375
Mailing Address - Fax:
Practice Address - Street 1:3525 PRESLEY AVE
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-4453
Practice Address - Country:US
Practice Address - Phone:951-955-9375
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-07-25
Last Update Date:2025-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-SNQMUV175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist