Healthcare Provider Details

I. General information

NPI: 1336116102
Provider Name (Legal Business Name): SCOTT ROBERT HANTSCH
Entity Type: Individual
Gender: Male
Sole Proprietor: X

II. Dates (important events)

Enumeration Date: 03/01/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

140 SYLVESTER RD
SAN DIEGO CA
92106-3521
US

IV. Provider business mailing address

9999 RIO SAN DIEGO DR
SAN DIEGO CA
92108-5630
US

V. Phone/Fax

Practice location:
  • Phone: 619-553-8719
  • Fax:
Mailing address:
  • Phone: 619-553-8713
  • Fax: 619-553-7758

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: