Provider Demographics
NPI:1053889063
Name:MENDOZA, LUIS
Entity type:Individual
Prefix:
First Name:LUIS
Middle Name:
Last Name:MENDOZA
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 1:11117 LOUISE AVE
Mailing Address - Street 2:
Mailing Address - City:LYNWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90262-3109
Mailing Address - Country:US
Mailing Address - Phone:310-314-6200
Mailing Address - Fax:310-450-2024
Practice Address - Street 1:905 PICO BLVD
Practice Address - Street 2:
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90405-1326
Practice Address - Country:US
Practice Address - Phone:310-314-6200
Practice Address - Fax:310-450-2024
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-07
Last Update Date:2018-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)