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General NPI Number Information
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NPI Number | 1912905472
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Entity Type | Individual
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Provider Name | DR. LARRY IVANCICH
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Gender | Male
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Dates
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Enumeration Date | 07/08/2005
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Last Update Date | 02/25/2008
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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 |
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Name |
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Credential |
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Telephone |
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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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