Healthcare Provider Details

I. General information

NPI: 1528438900
Provider Name (Legal Business Name): JOVANY BURGOS
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/29/2015
Last Update Date: 01/23/2025
Certification Date: 01/23/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1461 E COOLEY DR STE 100
COLTON CA
92324-3921
US

IV. Provider business mailing address

25910 ACERO STE 160
MISSION VIEJO CA
92691-2777
US

V. Phone/Fax

Practice location:
  • Phone: 909-835-4800
  • Fax: 909-347-9279
Mailing address:
  • Phone: 714-966-8684
  • Fax: 714-428-3103

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code101YM0800X
TaxonomyMental Health Counselor
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code172V00000X
TaxonomyCommunity Health Worker
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: