Healthcare Provider Details

I. General information

NPI: 1548069354
Provider Name (Legal Business Name): LARRY RICHARD OZAETA II
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/12/2025
Last Update Date: 03/12/2025
Certification Date: 03/12/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

43250 MIDNIGHT CT
BANNING CA
92220-9565
US

IV. Provider business mailing address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

V. Phone/Fax

Practice location:
  • Phone: 951-922-1725
  • Fax:
Mailing address:
  • Phone: 951-683-6596
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-LESYGV
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: