Provider Demographics
NPI:1679805188
Name:MILANA, IVAR BUSTAMANTE (RPT)
Entity Type:Individual
Prefix:MR
First Name:IVAR
Middle Name:BUSTAMANTE
Last Name:MILANA
Suffix:
Gender:M
Credentials:RPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29198 HYDRANGEA ST
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-4419
Mailing Address - Country:US
Mailing Address - Phone:951-672-0430
Mailing Address - Fax:951-672-0430
Practice Address - Street 1:29198 HYDRANGEA ST
Practice Address - Street 2:
Practice Address - City:MURRIETA
Practice Address - State:CA
Practice Address - Zip Code:92563-4419
Practice Address - Country:US
Practice Address - Phone:951-672-0430
Practice Address - Fax:951-672-0430
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-08
Last Update Date:2010-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA29606225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist