Healthcare Provider Details

I. General information

NPI: 1982320156
Provider Name (Legal Business Name): LOLA JONTIFF RAD T
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/18/2022
Last Update Date: 10/18/2022
Certification Date: 10/18/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

418 1/2 HELIOTROPE AVE
CORONA DEL MAR CA
92625
US

IV. Provider business mailing address

418 1/2 HELIOTROPE AVE
CORONA DEL MAR CA
92625
US

V. Phone/Fax

Practice location:
  • Phone: 786-683-6166
  • Fax:
Mailing address:
  • Phone: 786-683-6166
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code133N00000X
TaxonomyNutritionist
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code246Y00000X
TaxonomyHealth Information Specialist/Technologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: