Healthcare Provider Details

I. General information

NPI: 1548557648
Provider Name (Legal Business Name): ROMMEL JAVIER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/09/2011
Last Update Date: 04/09/2024
Certification Date: 04/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4729 HAWK RIDGE AVE
FONTANA CA
92336-0794
US

IV. Provider business mailing address

4729 HAWK RIDGE AVE
FONTANA CA
92336-0794
US

V. Phone/Fax

Practice location:
  • Phone: 909-816-5674
  • Fax:
Mailing address:
  • Phone: 909-816-5674
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367500000X
TaxonomyCertified Registered Nurse Anesthetist
License Number4183
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: