Healthcare Provider Details

I. General information

NPI: 1619895893
Provider Name (Legal Business Name): DANIEL PANJAITAN I
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/07/2026
Last Update Date: 07/07/2026
Certification Date: 07/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

400 N PEPPER AVE
COLTON CA
92324-1819
US

IV. Provider business mailing address

7625 OLEANDER AVE
FONTANA CA
92336-1935
US

V. Phone/Fax

Practice location:
  • Phone: 909-580-1800
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number744149
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: