Provider Demographics
NPI:1326578899
Name:IVY INFUSION LLC
Entity Type:Organization
Organization Name:IVY INFUSION LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:LESA
Authorized Official - Middle Name:
Authorized Official - Last Name:NICHOLES
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:281-773-7578
Mailing Address - Street 1:PO BOX 16461
Mailing Address - Street 2:
Mailing Address - City:SUGAR LAND
Mailing Address - State:TX
Mailing Address - Zip Code:77496-6461
Mailing Address - Country:US
Mailing Address - Phone:832-886-4774
Mailing Address - Fax:
Practice Address - Street 1:1201 CREEK WAY DR STE B
Practice Address - Street 2:
Practice Address - City:SUGAR LAND
Practice Address - State:TX
Practice Address - Zip Code:77478-4570
Practice Address - Country:US
Practice Address - Phone:832-886-4774
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-15
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207RI0200XAllopathic & Osteopathic PhysiciansInternal MedicineInfectious DiseaseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
1972766327OtherNPI