Healthcare Provider Details

I. General information

NPI: 1568912574
Provider Name (Legal Business Name): IVYFER DELA CRUZ
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/13/2016
Last Update Date: 10/13/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

73 SPECTRUM BLVD
LAS VEGAS NV
89101-4838
US

IV. Provider business mailing address

73 SPECTRUM BLVD
LAS VEGAS NV
89101-4838
US

V. Phone/Fax

Practice location:
  • Phone: 702-644-4673
  • Fax: 702-902-5443
Mailing address:
  • Phone: 702-644-4673
  • Fax: 702-902-5443

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number15015
License Number StateNV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: