Provider Demographics
NPI:1740419225
Name:LOPEZLLAVORE, IVAN (PTA)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:LOPEZLLAVORE
Suffix:
Gender:M
Credentials:PTA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3011 SABAL BEND DR NE
Mailing Address - Street 2:
Mailing Address - City:WINTER HAVEN
Mailing Address - State:FL
Mailing Address - Zip Code:33881-5108
Mailing Address - Country:US
Mailing Address - Phone:863-651-3040
Mailing Address - Fax:
Practice Address - Street 1:3011 SABAL BEND DR NE
Practice Address - Street 2:
Practice Address - City:WINTER HAVEN
Practice Address - State:FL
Practice Address - Zip Code:33881-5108
Practice Address - Country:US
Practice Address - Phone:863-651-3040
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-06
Last Update Date:2009-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPTA20203314000000X
FLNH4843376G00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
No376G00000XNursing Service Related ProvidersNursing Home Administrator