Provider Demographics
NPI:1306015086
Name:IVANCICH PODIATRY SERVICES, INC.
Entity Type:Organization
Organization Name:IVANCICH PODIATRY SERVICES, INC.
Other - Org Name:LARRY M. IVANCICH
Other - Org Type:Former Legal Business Name
Authorized Official - Title/Position:PODIATRIST
Authorized Official - Prefix:
Authorized Official - First Name:LARRY
Authorized Official - Middle Name:M
Authorized Official - Last Name:IVANCICH
Authorized Official - Suffix:
Authorized Official - Credentials:DPM
Authorized Official - Phone:626-401-2775
Mailing Address - Street 1:PO BOX 660025
Mailing Address - Street 2:
Mailing Address - City:ARCADIA
Mailing Address - State:CA
Mailing Address - Zip Code:91066-0025
Mailing Address - Country:US
Mailing Address - Phone:626-401-2775
Mailing Address - Fax:626-401-9826
Practice Address - Street 1:11800 VALLEY BLVD
Practice Address - Street 2:
Practice Address - City:EL MONTE
Practice Address - State:CA
Practice Address - Zip Code:91732-3040
Practice Address - Country:US
Practice Address - Phone:626-401-2775
Practice Address - Fax:626-401-9826
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-02-26
Last Update Date:2008-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAE3249213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatristGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA6099570001Medicare NSC
CA1092300001Medicare NSC
CAT19289Medicare UPIN