Healthcare Provider Details

I. General information

NPI: 1134823487
Provider Name (Legal Business Name): JUAN CARLO KOONTZ
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: JUAN CARLO PANTOJA

II. Dates (important events)

Enumeration Date: 03/29/2023
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2085 RUSTIN AVE UNIT 2
RIVERSIDE CA
92507-2498
US

IV. Provider business mailing address

200 E ALESSANDRO BLVD UNIT 44
RIVERSIDE CA
92508-6170
US

V. Phone/Fax

Practice location:
  • Phone: 951-955-2501
  • Fax:
Mailing address:
  • Phone: 951-419-1814
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code175T00000X
TaxonomyPeer Specialist
License NumberMPSS-WNVUHS
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: