Healthcare Provider Details

I. General information

NPI: 1982178471
Provider Name (Legal Business Name): MARC JANTZI LAC
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/17/2019
Last Update Date: 01/17/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4847 NEWPORT AVE
SAN DIEGO CA
92107-3110
US

IV. Provider business mailing address

1826 S COAST HWY
OCEANSIDE CA
92054-5322
US

V. Phone/Fax

Practice location:
  • Phone: 619-550-9747
  • Fax:
Mailing address:
  • Phone: 650-453-5179
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171100000X
TaxonomyAcupuncturist
License Number15038
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: