Provider Demographics
NPI:1629128376
Name:IVORY, BLANCA M (ACUPUNTURE PHYSICIAN)
Entity Type:Individual
Prefix:MS
First Name:BLANCA
Middle Name:M
Last Name:IVORY
Suffix:
Gender:F
Credentials:ACUPUNTURE PHYSICIAN
Other - Prefix:DR
Other - First Name:BLANCA
Other - Middle Name:M
Other - Last Name:IVORY
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MASSAGE THERAPIST
Mailing Address - Street 1:3109 GRAND AVE
Mailing Address - Street 2:#293
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33133-5103
Mailing Address - Country:US
Mailing Address - Phone:305-610-4989
Mailing Address - Fax:
Practice Address - Street 1:3109 GRAND AVE
Practice Address - Street 2:#293
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33133-5103
Practice Address - Country:US
Practice Address - Phone:305-610-4989
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-12
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAP 1024171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist