Provider Demographics
NPI:1700158672
Name:JURAVSKY, VITALY
Entity Type:Individual
Prefix:
First Name:VITALY
Middle Name:
Last Name:JURAVSKY
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 1:6860 HYDE PARK DR UNIT D
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92119-2228
Mailing Address - Country:US
Mailing Address - Phone:619-644-2363
Mailing Address - Fax:
Practice Address - Street 1:3853 ROSECRANS STREET SAN DIEGO, CA
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110
Practice Address - Country:US
Practice Address - Phone:619-692-8232
Practice Address - Fax:619-542-4060
Is Sole Proprietor?:No
Enumeration Date:2012-02-07
Last Update Date:2012-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA672933163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult