Provider Demographics
NPI:1902136112
Name:MENDIETA, RENE
Entity Type:Individual
Prefix:
First Name:RENE
Middle Name:
Last Name:MENDIETA
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 1:8850 AVALON BLVD
Mailing Address - Street 2:12
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90003-3575
Mailing Address - Country:US
Mailing Address - Phone:323-704-6260
Mailing Address - Fax:
Practice Address - Street 1:2677 ZOE AVE
Practice Address - Street 2:303
Practice Address - City:HUNTINGTON PARK
Practice Address - State:CA
Practice Address - Zip Code:90255-4195
Practice Address - Country:US
Practice Address - Phone:323-312-0640
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-01-11
Last Update Date:2010-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program