Provider Demographics
NPI:1730942640
Name:ONTIVEROS, CARLOS FABIAN
Entity type:Individual
Prefix:
First Name:CARLOS
Middle Name:FABIAN
Last Name:ONTIVEROS
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9109 SAN ANDRES ST
Mailing Address - Street 2:
Mailing Address - City:SPRING VALLEY
Mailing Address - State:CA
Mailing Address - Zip Code:91977-5845
Mailing Address - Country:US
Mailing Address - Phone:619-517-6848
Mailing Address - Fax:
Practice Address - Street 1:7826 BROADWAY
Practice Address - Street 2:
Practice Address - City:LEMON GROVE
Practice Address - State:CA
Practice Address - Zip Code:91945-1801
Practice Address - Country:US
Practice Address - Phone:619-876-4420
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-02
Last Update Date:2024-02-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT305326225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist