Healthcare Provider Details

I. General information

NPI: 1588336473
Provider Name (Legal Business Name): CARL REQUINTINA
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2021
Last Update Date: 09/29/2021
Certification Date: 09/29/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11060 REMINGTON CT
ADELANTO CA
92301-6138
US

IV. Provider business mailing address

11060 REMINGTON CT
ADELANTO CA
92301-6138
US

V. Phone/Fax

Practice location:
  • Phone: 909-549-3815
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code172A00000X
TaxonomyDriver
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: