Provider Demographics
NPI:1518597723
Name:VARGAS, IVAN JOSUE SR
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:JOSUE
Last Name:VARGAS
Suffix:SR
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8300 S VERMONT AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90044-3493
Mailing Address - Country:US
Mailing Address - Phone:323-525-6400
Mailing Address - Fax:213-382-0136
Practice Address - Street 1:8300 S VERMONT AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90044-3493
Practice Address - Country:US
Practice Address - Phone:323-525-6400
Practice Address - Fax:213-382-0136
Is Sole Proprietor?:No
Enumeration Date:2020-01-16
Last Update Date:2023-05-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAR1352400619101YA0400X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes101YA0400XBehavioral Health & Social Service ProvidersCounselorAddiction (Substance Use Disorder)