Provider Demographics
NPI:1144338013
Name:MENDONCA, LUIS M
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:M
Last Name:MENDONCA
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 1:171 BRISTOL AVE
Mailing Address - Street 2:
Mailing Address - City:PAWTUCKET
Mailing Address - State:RI
Mailing Address - Zip Code:02861-2240
Mailing Address - Country:US
Mailing Address - Phone:503-449-9745
Mailing Address - Fax:
Practice Address - Street 1:344 BROADWAY
Practice Address - Street 2:
Practice Address - City:REVERE
Practice Address - State:MA
Practice Address - Zip Code:02151-5016
Practice Address - Country:US
Practice Address - Phone:503-449-9745
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-08-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MA3086111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor