MEDICARE: KIMBERLY ILVENTO PPS

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	101YS0200X	School Counselor

General Provider Information

NPI Number	:	1942010921
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	KIMBERLY ILVENTO PPS

Provider Business Mailing Address
First Line	:	1735 LAKE TAHOE BLVD
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-3718
Country	:	US
Telephone Number	:	530-541-4111
Fax Number	:

Provider Business Practice Location Address
First Line	:	1735 LAKE TAHOE BLVD
Second Line	:
City	:	SOUTH LAKE TAHOE
State	:	CA
Zip	:	96150-3718
Country	:	US
Telephone Number	:	530-541-4111
Fax Number	:

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

Provider Enumeration Date	:	01/10/2025
Last Update Date	:	01/10/2025

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Directions to “ KIMBERLY ILVENTO PPS” Practice Location

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