MEDICARE: MR. BRODERIC D IVERY

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	225400000X	Rehabilitation Practitioner		NV

General Provider Information

NPI Number	:	1972844553
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. BRODERIC D IVERY

Provider Business Mailing Address
First Line	:	1915 ONA MARIE AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-4866
Country	:	US
Telephone Number	:	702-812-4973
Fax Number	:	702-631-6312

Provider Business Practice Location Address
First Line	:	1915 ONA MARIE AVE
Second Line	:
City	:	NORTH LAS VEGAS
State	:	NV
Zip	:	89032-4866
Country	:	US
Telephone Number	:	702-812-4973
Fax Number	:	702-631-6312

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

Provider Enumeration Date	:	03/07/2013
Last Update Date	:	03/07/2013

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