Healthcare Provider Details

I. General information

NPI: 1316420706
Provider Name (Legal Business Name): MS. IVETTE RIVAS BUGARIN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/11/2018
Last Update Date: 06/07/2024
Certification Date: 06/07/2024
Deactivation Date: 02/29/2024
Reactivation Date: 05/30/2024

III. Provider practice location address

330 MOSS ST
CHULA VISTA CA
91911-2005
US

IV. Provider business mailing address

330 MOSS ST
CHULA VISTA CA
91911-2005
US

V. Phone/Fax

Practice location:
  • Phone: 619-585-4221
  • Fax:
Mailing address:
  • Phone: 619-585-4221
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License Number120819
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: