Provider Demographics
NPI:1174063317
Name:IVITA, LLC
Entity type:Organization
Organization Name:IVITA, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:MYRNA
Authorized Official - Middle Name:
Authorized Official - Last Name:RAZO
Authorized Official - Suffix:
Authorized Official - Credentials:FNP-BC
Authorized Official - Phone:888-322-6432
Mailing Address - Street 1:590 RANCHO DE ORO RD
Mailing Address - Street 2:
Mailing Address - City:ESCONDIDO
Mailing Address - State:CA
Mailing Address - Zip Code:92026-3926
Mailing Address - Country:US
Mailing Address - Phone:888-322-6432
Mailing Address - Fax:888-329-6432
Practice Address - Street 1:590 RANCHO DE ORO RD
Practice Address - Street 2:
Practice Address - City:ESCONDIDO
Practice Address - State:CA
Practice Address - Zip Code:92026-3926
Practice Address - Country:US
Practice Address - Phone:888-322-6432
Practice Address - Fax:888-329-6432
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-03-07
Last Update Date:2017-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002919363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty