Basic Information
| Provider Information | |||||||||
| NPI: | 1144361015 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDIOLA | ||||||||
| FirstName: | MIKE | ||||||||
| MiddleName: | A | ||||||||
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| Credential: | BS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 8823 PRODUCTION LN | ||||||||
| Address2: | |||||||||
| City: | OOLTEWAH | ||||||||
| State: | TN | ||||||||
| PostalCode: | 373636511 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4232387217 | ||||||||
| FaxNumber: | 4232383473 | ||||||||
| Practice Location | |||||||||
| Address1: | 1004 PROGRESS DR | ||||||||
| Address2: | STE 100 | ||||||||
| City: | LANSING | ||||||||
| State: | KS | ||||||||
| PostalCode: | 660436326 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9133513838 | ||||||||
| FaxNumber: | 9133513939 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 02/12/2007 | ||||||||
| LastUpdateDate: | 04/24/2015 | ||||||||
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| ProviderGenderCode: | M | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | 070012819 | IL | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 11-04998 | KS | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist | 225100000X | 2015003684 | MO | N | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
ID Information
| ID | Type | State | Issuer | Description | MA4370099 | 01 | MO | MEDICARE PTAN | OTHER | 753561 | 01 | OPTUM | OTHER | KA2868072 | 01 | KS | MEDICARE PTAN | OTHER | USES NPI | 01 | KS | BCBS-KANSAS | OTHER |