Healthcare Provider Details

I. General information

NPI: 1689237901
Provider Name (Legal Business Name): SHARLINE NICOL RUVALCABA RADT-1
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2019
Last Update Date: 04/22/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8665 GIBBS DR STE 150
SAN DIEGO CA
92123-1739
US

IV. Provider business mailing address

1400 N JOHNSON AVE STE 101
EL CAJON CA
92020-1651
US

V. Phone/Fax

Practice location:
  • Phone: 858-384-6284
  • Fax: 858-384-6453
Mailing address:
  • Phone: 858-384-6284
  • Fax: 858-384-6453

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code101YA0400X
TaxonomyAddiction (Substance Use Disorder) Counselor
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: