Basic Information
| Provider Information | |||||||||
| NPI: | 1275861296 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | CHRISTINE | ||||||||
| MiddleName: | ELISABETH | ||||||||
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| Credential: | PTA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1652 CHOCTAW ST | ||||||||
| Address2: | |||||||||
| City: | SOUTH LAKE TAHOE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 961505215 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5305730831 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1573 MATHIAS PKWY | ||||||||
| Address2: | |||||||||
| City: | GARDNERVILLE | ||||||||
| State: | NV | ||||||||
| PostalCode: | 894107966 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7757826620 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 12/02/2009 | ||||||||
| LastUpdateDate: | 12/02/2009 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225200000X | A-0304 | NV | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapy Assistant |
No ID Information.