Provider Demographics
NPI:1962023317
Name:MARCANO, IVAN
Entity Type:Individual
Prefix:
First Name:IVAN
Middle Name:
Last Name:MARCANO
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5252 NW 85TH AVE APT 1005
Mailing Address - Street 2:
Mailing Address - City:DORAL
Mailing Address - State:FL
Mailing Address - Zip Code:33166-5332
Mailing Address - Country:US
Mailing Address - Phone:305-297-9695
Mailing Address - Fax:
Practice Address - Street 1:2240 SW 70TH AVE STE D
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33317-7112
Practice Address - Country:US
Practice Address - Phone:954-430-8000
Practice Address - Fax:954-212-0150
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-27
Last Update Date:2020-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA79241225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage TherapistGroup - Single Specialty