Provider Demographics
NPI:1467239152
Name:VILLALOBOS, BIVIANNA CHELSEA
Entity Type:Individual
Prefix:
First Name:BIVIANNA
Middle Name:CHELSEA
Last Name:VILLALOBOS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1231 MANDALAY ST
Mailing Address - Street 2:
Mailing Address - City:ONTARIO
Mailing Address - State:CA
Mailing Address - Zip Code:91764-2225
Mailing Address - Country:US
Mailing Address - Phone:909-358-5590
Mailing Address - Fax:
Practice Address - Street 1:1231 MANDALAY ST
Practice Address - Street 2:
Practice Address - City:ONTARIO
Practice Address - State:CA
Practice Address - Zip Code:91764-2225
Practice Address - Country:US
Practice Address - Phone:909-358-5590
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-14
Last Update Date:2023-09-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA172V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker