Provider Demographics
NPI:1821742701
Name:IVY DIAGNOSTICS LLC
Entity Type:Organization
Organization Name:IVY DIAGNOSTICS LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:RONNETTE
Authorized Official - Last Name:GRAY
Authorized Official - Suffix:
Authorized Official - Credentials:DMD
Authorized Official - Phone:972-922-5321
Mailing Address - Street 1:915 W EXCHANGE PKWY STE 280
Mailing Address - Street 2:
Mailing Address - City:ALLEN
Mailing Address - State:TX
Mailing Address - Zip Code:75013-7031
Mailing Address - Country:US
Mailing Address - Phone:972-922-5321
Mailing Address - Fax:
Practice Address - Street 1:915 W EXCHANGE PKWY STE 280
Practice Address - Street 2:
Practice Address - City:ALLEN
Practice Address - State:TX
Practice Address - Zip Code:75013-7031
Practice Address - Country:US
Practice Address - Phone:972-922-5321
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-02-09
Last Update Date:2022-02-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes291U00000XLaboratoriesClinical Medical Laboratory