MEDICARE: MR. SCOTT DOUGLAS IVY

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	372500000X	Chore Provider		FL
2	175T00000X	Peer Specialist		FL

General Provider Information

NPI Number	:	1235837774
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MR. SCOTT DOUGLAS IVY

Provider Business Mailing Address
First Line	:	11004 ROCKLEDGE VIEW DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33579-2370
Country	:	US
Telephone Number	:	813-531-2383
Fax Number	:	813-922-0223

Provider Business Practice Location Address
First Line	:	11004 ROCKLEDGE VIEW DR
Second Line	:
City	:	RIVERVIEW
State	:	FL
Zip	:	33579-2370
Country	:	US
Telephone Number	:	813-531-2383
Fax Number	:	813-922-0223

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	02/22/2023
Last Update Date	:	02/22/2023

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