Provider Demographics
NPI:1659967735
Name:FLORES, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:FLORES
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:38 ROGERS ST
Mailing Address - Street 2:
Mailing Address - City:TUCKAHOE
Mailing Address - State:NY
Mailing Address - Zip Code:10707-3412
Mailing Address - Country:US
Mailing Address - Phone:845-667-1636
Mailing Address - Fax:
Practice Address - Street 1:38 ROGERS ST
Practice Address - Street 2:
Practice Address - City:TUCKAHOE
Practice Address - State:NY
Practice Address - Zip Code:10707-3412
Practice Address - Country:US
Practice Address - Phone:845-667-1636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-12-14
Last Update Date:2020-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY335638-01164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes164W00000XNursing Service ProvidersLicensed Practical NurseGroup - Single Specialty