Healthcare Provider Details

I. General information

NPI: 1912905472
Provider Name (Legal Business Name): DR. LARRY IVANCICH
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

Provider Other Name: LARRY M. IVANCICH D.P.M.

II. Dates (important events)

Enumeration Date: 07/08/2005
Last Update Date: 02/25/2008
Certification Date:
Deactivation Date: 03/15/2006
Reactivation Date: 03/29/2006

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:
Title or Position:
Credential:
Phone: