Basic Information
| Provider Information | |||||||||
| NPI: | 1508045089 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | ILUMINADA | ||||||||
| MiddleName: | CANLAS | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | PT | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | CANLAS | ||||||||
| OtherFirstName: | ILUMINADA | ||||||||
| OtherMiddleName: | PANGILINAN | ||||||||
| OtherNamePrefix: | MISS | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | PT | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 3290 NORTH RIDGE ROAD EXECUTIVE CENTER II | ||||||||
| Address2: | SUITE 290 | ||||||||
| City: | ELLICOTT CITY | ||||||||
| State: | MD | ||||||||
| PostalCode: | 210433655 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4107509006 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3201 W COMMERCIAL BLVD | ||||||||
| Address2: | SUITE 116 | ||||||||
| City: | FORT LAUDERDALE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333093440 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9543324445 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 10/31/2007 | ||||||||
| LastUpdateDate: | 10/31/2007 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | MD | Y | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.