Provider Demographics
NPI:1972844553
Name:IVERY, BRODERIC D
Entity Type:Individual
Prefix:MR
First Name:BRODERIC
Middle Name:D
Last Name:IVERY
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 1:1915 ONA MARIE AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89032-4866
Mailing Address - Country:US
Mailing Address - Phone:702-812-4973
Mailing Address - Fax:702-631-6312
Practice Address - Street 1:1915 ONA MARIE AVE
Practice Address - Street 2:
Practice Address - City:NORTH LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89032-4866
Practice Address - Country:US
Practice Address - Phone:702-812-4973
Practice Address - Fax:702-631-6312
Is Sole Proprietor?:Yes
Enumeration Date:2013-03-07
Last Update Date:2013-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NV225400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225400000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersRehabilitation Practitioner