1306015086 NPI number — IVANCICH PODIATRY SERVICES, INC.

Table of content: (NPI 1306015086)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1306015086 NPI number — IVANCICH PODIATRY SERVICES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IVANCICH PODIATRY SERVICES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
LARRY M. IVANCICH
Provider Other Organization Name Type Code:
4
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1306015086
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
09/11/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 660025
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
ARCADIA
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
91066-0025
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
626-401-2775
Provider Business Mailing Address Fax Number:
626-401-9826

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
11800 VALLEY BLVD
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
EL MONTE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
91732-3040
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
626-401-2775
Provider Business Practice Location Address Fax Number:
626-401-9826
Provider Enumeration Date:
02/26/2008

Additional Information

Authorized Official

Authorized Official Last Name:
IVANCICH
Authorized Official First Name:
LARRY
Authorized Official Middle Name:
M.
Authorized Official Title or Position:
PODIATRIST
Authorized Official Telephone Number:
626-401-2775

Provider Taxonomy Codes

  • Taxonomy code: 213E00000X , with the licence number:  E3249 , registered in the state of CA ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





Copyright © 2007-2024 www.npivalidator.com