Provider Demographics
NPI:1679626865
Name:BERNAVE, JAMES R
Entity Type:Individual
Prefix:MR
First Name:JAMES
Middle Name:R
Last Name:BERNAVE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:JAMES
Other - Middle Name:R
Other - Last Name:BERNAVE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:RPT
Mailing Address - Street 1:1976 HACIENDA DRIVE
Mailing Address - Street 2:
Mailing Address - City:VISTA
Mailing Address - State:CA
Mailing Address - Zip Code:92081-6025
Mailing Address - Country:US
Mailing Address - Phone:760-758-4770
Mailing Address - Fax:760-758-3274
Practice Address - Street 1:1976 HACIENDA DR
Practice Address - Street 2:
Practice Address - City:VISTA
Practice Address - State:CA
Practice Address - Zip Code:92081-6025
Practice Address - Country:US
Practice Address - Phone:760-758-4770
Practice Address - Fax:760-758-3274
Is Sole Proprietor?:No
Enumeration Date:2007-01-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAPT239174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CAWPT239AMedicare ID - Type Unspecified