Healthcare Provider Details

I. General information

NPI: 1952902850
Provider Name (Legal Business Name): IVORA INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/06/2020
Last Update Date: 02/16/2022
Certification Date: 02/16/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13894 S BANGERTER PKWY STE 200
DRAPER UT
84020-5320
US

IV. Provider business mailing address

10885 S LOSTWOOD DR
SANDY UT
84092-4925
US

V. Phone/Fax

Practice location:
  • Phone: 801-901-3603
  • Fax:
Mailing address:
  • Phone: 954-702-3372
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: STEPHEN M FABIANO
Title or Position: CEO
Credential:
Phone: 954-702-3372