Basic Information
Provider Information | |||||||||
NPI: | 1902017932 | ||||||||
EntityType: | 2 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: | THEOPHIL JANTZ, D.O., INC | ||||||||
LastName: |   | ||||||||
FirstName: |   | ||||||||
MiddleName: |   | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: |   | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | PO BOX 34120 | ||||||||
Address2: |   | ||||||||
City: | RENO | ||||||||
State: | NV | ||||||||
PostalCode: | 895334120 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7757475050 | ||||||||
FaxNumber: | 7757475005 | ||||||||
Practice Location | |||||||||
Address1: | 721 RIVER DR | ||||||||
Address2: | STE B | ||||||||
City: | FORT BRAGG | ||||||||
State: | CA | ||||||||
PostalCode: | 95437 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 7757475050 | ||||||||
FaxNumber: | 7757475005 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 05/24/2007 | ||||||||
LastUpdateDate: | 08/22/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: |   | ||||||||
AuthorizedOfficialLastName: | JANTZ | ||||||||
AuthorizedOfficialFirstName: | THEOPHIL | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
AuthorizedOfficialTelephone: | 7079646910 | ||||||||
IsSoleProprietor: |   | ||||||||
IsOrganizationSubpart: | N | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: | D.O. | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 208600000X | 20A9193 | CA | Y | 193400000X SINGLE SPECIALTY GROUP | Allopathic & Osteopathic Physicians | Surgery |   |
No ID Information.