Healthcare Provider Details

I. General information

NPI: 1063836872
Provider Name (Legal Business Name): MR. JUSTIN PERNELL KATER
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/13/2014
Last Update Date: 08/07/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2020 IOWA AVE SUIT #101
RIVERSIDE CA
92507
US

IV. Provider business mailing address

2020 IOWA AVE SUIT # 101
RIVERSIDE CA
92507
US

V. Phone/Fax

Practice location:
  • Phone: 951-384-4699
  • Fax: 626-294-1079
Mailing address:
  • Phone: 951-384-4699
  • Fax: 626-294-1079

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101Y00000X
TaxonomyCounselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: