Healthcare Provider Details

I. General information

NPI: 1902017932
Provider Name (Legal Business Name): THEOPHIL JANTZ, D.O., INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/24/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

721 RIVER DR STE B
FORT BRAGG CA
95437
US

IV. Provider business mailing address

PO BOX 34120
RENO NV
89533-4120
US

V. Phone/Fax

Practice location:
  • Phone: 775-747-5050
  • Fax: 775-747-5005
Mailing address:
  • Phone: 775-747-5050
  • Fax: 775-747-5005

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208600000X
TaxonomySurgery Physician
License Number20A9193
License Number StateCA

VIII. Authorized Official

Name: THEOPHIL JANTZ
Title or Position: OWNER
Credential: D.O.
Phone: 707-964-6910