Provider Demographics
NPI:1134823487
Name:KOONTZ, JUAN CARLO
Entity type:Individual
Prefix:
First Name:JUAN
Middle Name:CARLO
Last Name:KOONTZ
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JUAN
Other - Middle Name:CARLO
Other - Last Name:PANTOJA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:200 E ALESSANDRO BLVD UNIT 44
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92508-6170
Mailing Address - Country:US
Mailing Address - Phone:951-419-1814
Mailing Address - Fax:
Practice Address - Street 1:2085 RUSTIN AVE UNIT 2
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-2498
Practice Address - Country:US
Practice Address - Phone:951-955-2501
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-03-29
Last Update Date:2023-07-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAMPSS-WNVUHS175T00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist