Provider Demographics
NPI:1497588388
Name:MERCADO, THEODORE (RN)
Entity type:Individual
Prefix:MR
First Name:THEODORE
Middle Name:
Last Name:MERCADO
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11626 DEERFIELD DR
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-6826
Mailing Address - Country:US
Mailing Address - Phone:909-379-3850
Mailing Address - Fax:
Practice Address - Street 1:191 N SUNRISE WAY
Practice Address - Street 2:
Practice Address - City:PALM SPRINGS
Practice Address - State:CA
Practice Address - Zip Code:92262-5201
Practice Address - Country:US
Practice Address - Phone:909-379-3850
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA529599163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC1500XNursing Service ProvidersRegistered NurseCommunity Health