Healthcare Provider Details

I. General information

NPI: 1306015086
Provider Name (Legal Business Name): IVANCICH PODIATRY SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/26/2008
Last Update Date: 09/11/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11800 VALLEY BLVD
EL MONTE CA
91732-3040
US

IV. Provider business mailing address

PO BOX 660025
ARCADIA CA
91066-0025
US

V. Phone/Fax

Practice location:
  • Phone: 626-401-2775
  • Fax: 626-401-9826
Mailing address:
  • Phone: 626-401-2775
  • Fax: 626-401-9826

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code213E00000X
TaxonomyPodiatrist
License NumberE3249
License Number StateCA

VIII. Authorized Official

Name: LARRY M. IVANCICH
Title or Position: PODIATRIST
Credential: D.P.M.
Phone: 626-401-2775