Healthcare Provider Details

I. General information

NPI: 1316225519
Provider Name (Legal Business Name): EDWARD JOHN RONQUILLO SF IDC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/22/2011
Last Update Date: 07/22/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1642 HICKORY NUT PL
CHULA VISTA CA
91915-1728
US

IV. Provider business mailing address

1642 HICKORY NUT PL
CHULA VISTA CA
91915-1728
US

V. Phone/Fax

Practice location:
  • Phone: 858-922-5269
  • Fax:
Mailing address:
  • Phone: 858-922-5269
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: