Provider Demographics
NPI:1053437046
Name:MENDOZA, PERCELINA (PT, DPT)
Entity type:Individual
Prefix:
First Name:PERCELINA
Middle Name:
Last Name:MENDOZA
Suffix:
Gender:F
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:155 W 13TH ST N
Mailing Address - Street 2:
Mailing Address - City:CHEYENNE WELLS
Mailing Address - State:CO
Mailing Address - Zip Code:80810-9504
Mailing Address - Country:US
Mailing Address - Phone:719-767-8717
Mailing Address - Fax:
Practice Address - Street 1:KEEFE MEMORIAL HOSPITAL
Practice Address - Street 2:602 NORTH 6TH WEST
Practice Address - City:CHEYENNE WELLS
Practice Address - State:CO
Practice Address - Zip Code:80810
Practice Address - Country:US
Practice Address - Phone:719-767-5662
Practice Address - Fax:719-767-8042
Is Sole Proprietor?:No
Enumeration Date:2007-03-21
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO6758225100000X
NE1529225100000X
DEJ1-0001065225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist