Healthcare Provider Details

I. General information

NPI: 1407652647
Provider Name (Legal Business Name): IVANOVSKY LAZARE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 02/19/2025
Certification Date: 02/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3207 N 168TH AVE
OMAHA NE
68116-2646
US

IV. Provider business mailing address

3207 N 168TH AVE
OMAHA NE
68116-2646
US

V. Phone/Fax

Practice location:
  • Phone: 347-248-4499
  • Fax:
Mailing address:
  • Phone: 347-248-4499
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number State
# 3
Primary TaxonomyY
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: