Healthcare Provider Details

I. General information

NPI: 1174063317
Provider Name (Legal Business Name): IVITA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2017
Last Update Date: 03/07/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

590 RANCHO DE ORO RD
ESCONDIDO CA
92026-3926
US

IV. Provider business mailing address

590 RANCHO DE ORO RD
ESCONDIDO CA
92026-3926
US

V. Phone/Fax

Practice location:
  • Phone: 888-322-6432
  • Fax: 888-329-6432
Mailing address:
  • Phone: 888-322-6432
  • Fax: 888-329-6432

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95002919
License Number StateCA

VIII. Authorized Official

Name: MYRNA RAZO
Title or Position: OWNER
Credential: FNP-BC
Phone: 888-322-6432