Healthcare Provider Details

I. General information

NPI: 1619385739
Provider Name (Legal Business Name): ROBERT RONNIE PONTECORVO JR. ACUPUNCTURE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/01/2014
Last Update Date: 04/15/2026
Certification Date: 04/15/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

814 W LODI AVE
LODI CA
95240-3302
US

IV. Provider business mailing address

814 W LODI AVE
LODI CA
95240-3302
US

V. Phone/Fax

Practice location:
  • Phone: 209-327-9961
  • Fax: 209-904-7015
Mailing address:
  • Phone: 209-327-9961
  • Fax: 209-904-7015

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number15877
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: