Healthcare Provider Details

I. General information

NPI: 1679760573
Provider Name (Legal Business Name): ROSHALLY ELVY HUTABARAT LVN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/25/2007
Last Update Date: 09/25/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

264 E 18TH ST
SAN BERNARDINO CA
92404-4708
US

IV. Provider business mailing address

25502 PORTOLA LOOP
LOMA LINDA CA
92354
US

V. Phone/Fax

Practice location:
  • Phone: 909-883-0288
  • Fax:
Mailing address:
  • Phone: 909-796-2303
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License NumberVA 209395
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: