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General NPI Number Information
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NPI Number | 1306015086
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Entity Type | Organization
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Legal Business Name | IVANCICH PODIATRY SERVICES, INC.
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Dates
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Enumeration Date | 02/26/2008
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Last Update Date | 09/11/2008
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Provider Practice Location Address
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Address Line | 11800 VALLEY BLVD
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City | EL MONTE
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State | CA
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Zip | 91732-3040
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Country | US
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Telephone | 626-401-2775
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Fax | 626-401-9826
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Provider Business Mailing Address
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Address Line | PO BOX 660025
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City | ARCADIA
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State | CA
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Zip | 91066-0025
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Country | US
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Telephone | 626-401-2775
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Fax | 626-401-9826
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Authorized Official
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Title or Position | PODIATRIST
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Name | LARRY M. IVANCICH
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Credential | D.P.M.
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Telephone | 626-401-2775
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 213E00000X
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Taxonomy Name | Podiatrist
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License Number | E3249
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License Number State | CA
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