Healthcare Provider Details

I. General information

NPI: 1841126638
Provider Name (Legal Business Name): IVAN VINGUA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/20/2026
Last Update Date: 06/20/2026
Certification Date: 06/20/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 W CALIFORNIA BLVD
PASADENA CA
91105-3010
US

IV. Provider business mailing address

570 S ORANGE GROVE BLVD
PASADENA CA
91105-1709
US

V. Phone/Fax

Practice location:
  • Phone: 626-397-2318
  • Fax:
Mailing address:
  • Phone: 626-397-2318
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number95242113
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: