Healthcare Provider Details

I. General information

NPI: 1821906199
Provider Name (Legal Business Name): IVYMAZE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/28/2026
Last Update Date: 08/28/2026
Certification Date: 08/28/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1101B LIBERTY AVE
BROOKLYN NY
11208-2945
US

IV. Provider business mailing address

2015 E 61ST ST
BROOKLYN NY
11234-5907
US

V. Phone/Fax

Practice location:
  • Phone: 917-402-8232
  • Fax:
Mailing address:
  • Phone: 917-402-8232
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State

VIII. Authorized Official

Name: MIRAFLORE J VILLABRERA
Title or Position: CEO
Credential:
Phone: 917-402-8232