Provider Demographics
NPI:1902045412
Name:VICZKO, LIVIA (LMT)
Entity Type:Individual
Prefix:
First Name:LIVIA
Middle Name:
Last Name:VICZKO
Suffix:
Gender:F
Credentials:LMT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12164 79TH CT N
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33412-2262
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12164 79TH CT N
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33412-2262
Practice Address - Country:US
Practice Address - Phone:561-236-4760
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-02-08
Last Update Date:2009-02-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA 36143174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist