Provider Demographics
NPI:1083635692
Name:IVY LANE PEDIATRICS, LLC
Entity Type:Organization
Organization Name:IVY LANE PEDIATRICS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:WYNDAM
Authorized Official - Middle Name:
Authorized Official - Last Name:REEVE
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:801-774-9698
Mailing Address - Street 1:5974 FASHION POINT DR STE 230
Mailing Address - Street 2:
Mailing Address - City:SOUTH OGDEN
Mailing Address - State:UT
Mailing Address - Zip Code:84403-4805
Mailing Address - Country:US
Mailing Address - Phone:801-774-9698
Mailing Address - Fax:801-728-0641
Practice Address - Street 1:5974 FASHION POINT DR STE 230
Practice Address - Street 2:
Practice Address - City:SOUTH OGDEN
Practice Address - State:UT
Practice Address - Zip Code:84403-4805
Practice Address - Country:US
Practice Address - Phone:801-774-9698
Practice Address - Fax:801-728-0641
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-07-21
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
UT467230Medicare Oscar/Certification