Individual
EDGAR ONTIVEROS
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Contact information
Practice address
14096 LAKESHORE DR, CLEARLAKE, CA 95422-8160
(707) 994-4261
Mailing address
PO BOX 1024, LUCERNE, CA 95458-1024
(707) 274-9101
Taxonomy
Speciality
Code
Description
License number
State
175T00000X
Peer Specialist
Primary
MPSS-WEYLRB
CA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
1326252271
1326252271
CA
Enumeration date
10/28/2024
Last updated
10/30/2024
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