1710585617 NPI number — IVY HEALTHCARE

Table of content: (NPI 1710585617)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1710585617 NPI number — IVY HEALTHCARE

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
IVY HEALTHCARE
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:
Provider Other Organization Name Type Code:
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:
1710585617
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
01/07/2021
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
PO BOX 6059
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LONGVIEW
Provider Business Mailing Address State Name:
TX
Provider Business Mailing Address Postal Code:
75608-6059
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
903-918-8520
Provider Business Mailing Address Fax Number:
866-842-1649

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
1100 N 4TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LONGVIEW
Provider Business Practice Location Address State Name:
TX
Provider Business Practice Location Address Postal Code:
75601-4739
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
903-918-8520
Provider Business Practice Location Address Fax Number:
866-842-1649
Provider Enumeration Date:
10/13/2020

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
BRINKMAN
Authorized Official First Name:
SHEILA
Authorized Official Middle Name:
Authorized Official Title or Position:
OWNER/PROVIDER
Authorized Official Telephone Number:
903-918-8520

Provider Taxonomy Codes

  • Taxonomy code: 363LF0000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: AP140963 . This is a "LICENSE TO PRACTICE" identifier , issued by the state of ( TX ) . This identifiers is of the category "OTHER".