Basic Information
| Provider Information | |||||||||
| NPI: | 1649824848 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MENDOZA | ||||||||
| FirstName: | SANTANA | ||||||||
| MiddleName: | |||||||||
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| Credential: | PEER SUPPORT SPECIAL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3465 MCNUTT RD | ||||||||
| Address2: | |||||||||
| City: | SUNLAND PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880639056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5759151338 | ||||||||
| FaxNumber: | 5759151819 | ||||||||
| Practice Location | |||||||||
| Address1: | 3465 MCNUTT RD | ||||||||
| Address2: | |||||||||
| City: | SUNLAND PARK | ||||||||
| State: | NM | ||||||||
| PostalCode: | 880639056 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5759151338 | ||||||||
| FaxNumber: | 5759151819 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 07/26/2019 | ||||||||
| LastUpdateDate: | 07/26/2019 | ||||||||
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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 | 175T00000X | 2021 | NM | Y |
ID Information
| ID | Type | State | Issuer | Description | 24256536 | 05 | NM | MEDICAID |