Healthcare Provider Details

I. General information

NPI: 1336289818
Provider Name (Legal Business Name): MR. HERBERT RAY BUMGART JR.
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/07/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1295 STATE ST SUITE 106
EL CENTRO CA
92251
US

IV. Provider business mailing address

1295 STATE ST SUITE 106
EL CENTRO CA
92251
US

V. Phone/Fax

Practice location:
  • Phone: 760-336-8534
  • Fax: 760-337-7885
Mailing address:
  • Phone: 760-336-8534
  • Fax: 760-337-7885

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225C00000X
TaxonomyRehabilitation Counselor
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: