MEDICARE: DEBORAH JEAN IVORY C.S.A.

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	246ZS0410X	Surgical Technologist

General Provider Information

NPI Number	:	1093782385
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DEBORAH JEAN IVORY C.S.A.

Provider Business Mailing Address
First Line	:	1601 DUKE OF WINDSOR RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2505
Country	:	US
Telephone Number	:	757-496-3477
Fax Number	:

Provider Business Practice Location Address
First Line	:	1601 DUKE OF WINDSOR RD
Second Line	:
City	:	VIRGINIA BEACH
State	:	VA
Zip	:	23454-2505
Country	:	US
Telephone Number	:	757-216-7458
Fax Number	:	757-496-5110

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/05/2006
Last Update Date	:	07/08/2007

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