Healthcare Provider Details

I. General information

NPI: 1104672153
Provider Name (Legal Business Name): MR. JOHN FRANK DZENCELOWCZ II
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/29/2024
Last Update Date: 04/29/2024
Certification Date: 04/29/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 S FREMONT AVE # A-11
ALHAMBRA CA
91803-8800
US

IV. Provider business mailing address

4307 JEAN AVE
DURHAM NC
27707-5050
US

V. Phone/Fax

Practice location:
  • Phone: 626-457-4240
  • Fax:
Mailing address:
  • Phone: 704-965-1022
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: