Healthcare Provider Details

I. General information

NPI: 1174388375
Provider Name (Legal Business Name): DANNIE NAINGGOLAN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/16/2024
Last Update Date: 07/30/2025
Certification Date: 07/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

17270 ROOSEVELT ST
RIVERSIDE CA
92508-9523
US

IV. Provider business mailing address

5870 ARLINGTON AVE
RIVERSIDE CA
92504-2037
US

V. Phone/Fax

Practice location:
  • Phone: 951-780-2514
  • Fax:
Mailing address:
  • Phone: 951-683-6596
  • Fax: 951-373-5992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code167G00000X
TaxonomyLicensed Psychiatric Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: