Healthcare Provider Details

I. General information

NPI: 1417138272
Provider Name (Legal Business Name): RICHARD IVY
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/21/2007
Last Update Date: 11/21/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7235 WHIPPLE AVE NW
NORTH CANTON OH
44720-7137
US

IV. Provider business mailing address

328 FAIRVIEW AVE
GALION OH
44833-2012
US

V. Phone/Fax

Practice location:
  • Phone: 330-498-8200
  • Fax:
Mailing address:
  • Phone: 419-631-4396
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225200000X
TaxonomyPhysical Therapy Assistant
License NumberPTA.03726
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: