Healthcare Provider Details

I. General information

NPI: 1932468477
Provider Name (Legal Business Name): ROBYN JILL HEIDENREICH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2012
Last Update Date: 12/01/2021
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17284 SLOVER AVE STE 106
FONTANA CA
92337-7584
US

IV. Provider business mailing address

17284 SLOVER AVE STE 106
FONTANA CA
92337-7584
US

V. Phone/Fax

Practice location:
  • Phone: 909-609-3500
  • Fax: 909-609-3548
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QG0300X
TaxonomyGeriatric Medicine (Family Medicine) Physician
License NumberA127325
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: