Provider Demographics
NPI:1689031262
Name:IVPS OF DELAWARE
Entity Type:Organization
Organization Name:IVPS OF DELAWARE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:JENEANE
Authorized Official - Middle Name:
Authorized Official - Last Name:WAKULA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:772-546-9591
Mailing Address - Street 1:8929 SE BRIDGE ROAD
Mailing Address - Street 2:
Mailing Address - City:HOBE SOUND
Mailing Address - State:FL
Mailing Address - Zip Code:33455
Mailing Address - Country:US
Mailing Address - Phone:772-546-9591
Mailing Address - Fax:
Practice Address - Street 1:1305 KIRKWOOD HIGHWAY
Practice Address - Street 2:
Practice Address - City:WILMINGTON
Practice Address - State:DE
Practice Address - Zip Code:19805
Practice Address - Country:US
Practice Address - Phone:302-994-6575
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-01-27
Last Update Date:2016-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEC2-0010908174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes174400000XOther Service ProvidersSpecialistGroup - Single Specialty