Healthcare Provider Details

I. General information

NPI: 1972958981
Provider Name (Legal Business Name): ELIZABETH IWANKOVITSCH
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/27/2016
Last Update Date: 04/27/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

32131 HEATHWOOD ST
SAINT CLAIR SHORES MI
48082-2204
US

IV. Provider business mailing address

32131 HEATHWOOD ST
SAINT CLAIR SHORES MI
48082-2204
US

V. Phone/Fax

Practice location:
  • Phone: 586-863-3025
  • Fax:
Mailing address:
  • Phone: 586-863-3025
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: