Provider Demographics
NPI:1770718769
Name:MENDEZ MEDICAL, LLC
Entity type:Organization
Organization Name:MENDEZ MEDICAL, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:ALEX
Authorized Official - Middle Name:
Authorized Official - Last Name:MENDEZ
Authorized Official - Suffix:
Authorized Official - Credentials:RRT
Authorized Official - Phone:580-303-9275
Mailing Address - Street 1:209 W. BROADWAY
Mailing Address - Street 2:
Mailing Address - City:ELK CITY
Mailing Address - State:OK
Mailing Address - Zip Code:73644-4741
Mailing Address - Country:US
Mailing Address - Phone:580-303-9275
Mailing Address - Fax:580-303-9236
Practice Address - Street 1:209 W BROADWAY AVE
Practice Address - Street 2:
Practice Address - City:ELK CITY
Practice Address - State:OK
Practice Address - Zip Code:73644-4741
Practice Address - Country:US
Practice Address - Phone:580-303-9275
Practice Address - Fax:580-303-9236
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-05-20
Last Update Date:2009-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
OK100796430AMedicaid
OK100796430AMedicaid