Healthcare Provider Details

I. General information

NPI: 1720481948
Provider Name (Legal Business Name): IVAN LUKE WEST SR.
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/01/2014
Last Update Date: 10/01/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

175 CIDER RUN
MAGNOLIA DE
19962-1667
US

IV. Provider business mailing address

175 CIDER RUN
MAGNOLIA DE
19962-1667
US

V. Phone/Fax

Practice location:
  • Phone: 302-233-8622
  • Fax:
Mailing address:
  • Phone: 302-233-8622
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberJ2-0000771
License Number StateDE

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: