Provider Demographics
NPI:1558733824
Name:IRVIN, GINA
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:IRVIN
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 1:771 W BLAINE ST # C
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-3940
Mailing Address - Country:US
Mailing Address - Phone:951-358-4588
Mailing Address - Fax:
Practice Address - Street 1:771 W BLAINE ST # C
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92507-3940
Practice Address - Country:US
Practice Address - Phone:951-358-4588
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-27
Last Update Date:2016-04-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes175T00000XOther Service ProvidersPeer Specialist