Provider Demographics
NPI:1841780574
Name:SUNGA, JAYVIN DAVID
Entity Type:Individual
Prefix:
First Name:JAYVIN
Middle Name:DAVID
Last Name:SUNGA
Suffix:
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 1:2307 1/2 BELLEVIEW AVE
Mailing Address - Street 2:
Mailing Address - City:LA JUNTA
Mailing Address - State:CO
Mailing Address - Zip Code:81050-3307
Mailing Address - Country:US
Mailing Address - Phone:719-417-0099
Mailing Address - Fax:
Practice Address - Street 1:900 S 12TH ST
Practice Address - Street 2:
Practice Address - City:ROCKY FORD
Practice Address - State:CO
Practice Address - Zip Code:81067-2128
Practice Address - Country:US
Practice Address - Phone:719-254-3314
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-17
Last Update Date:2018-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
COPTL.0015488225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO1346697471Medicaid