Healthcare Provider Details

I. General information

NPI: 1891048435
Provider Name (Legal Business Name): MR. IVAN PIERCE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/19/2012
Last Update Date: 10/22/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1301 PIERCE ST
SAN FRANCISCO CA
94115-4005
US

IV. Provider business mailing address

1301 PIERCE ST
SAN FRANCISCO CA
94115-4005
US

V. Phone/Fax

Practice location:
  • Phone: 415-563-8200
  • Fax: 415-563-5985
Mailing address:
  • Phone: 415-563-8200
  • Fax: 415-563-5985

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License NumberRI-P12091020228
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: