Provider Demographics
NPI:1851001911
Name:HENRIQUEZ, IVAN (ATC)
Entity Type:Individual
Prefix:MR
First Name:IVAN
Middle Name:
Last Name:HENRIQUEZ
Suffix:
Gender:M
Credentials:ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8515 BERGENLINE AVE APT 1A
Mailing Address - Street 2:
Mailing Address - City:NORTH BERGEN
Mailing Address - State:NJ
Mailing Address - Zip Code:07047-5162
Mailing Address - Country:US
Mailing Address - Phone:201-654-1513
Mailing Address - Fax:
Practice Address - Street 1:55 MEADOWLANDS PKWY
Practice Address - Street 2:
Practice Address - City:SECAUCUS
Practice Address - State:NJ
Practice Address - Zip Code:07094-2977
Practice Address - Country:US
Practice Address - Phone:201-392-3424
Practice Address - Fax:201-392-3056
Is Sole Proprietor?:No
Enumeration Date:2022-11-30
Last Update Date:2022-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ20000526612255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer