Healthcare Provider Details

I. General information

NPI: 1710808316
Provider Name (Legal Business Name): KEITH BERNARD KOZIOL
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/22/2026
Last Update Date: 07/22/2026
Certification Date: 07/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11155 MOUNTAIN VIEW AVE STE 220
LOMA LINDA CA
92354-3873
US

IV. Provider business mailing address

92 KANSAS ST APT E14
REDLANDS CA
92373-5410
US

V. Phone/Fax

Practice location:
  • Phone: 909-558-6716
  • Fax:
Mailing address:
  • Phone: 818-631-3011
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code103G00000X
TaxonomyClinical Neuropsychologist
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: