Provider Demographics
NPI:1013488774
Name:SPIVAK, ILYA (DC)
Entity Type:Individual
Prefix:DR
First Name:ILYA
Middle Name:
Last Name:SPIVAK
Suffix:
Gender:M
Credentials:DC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1580 SHORELINE WAY
Mailing Address - Street 2:
Mailing Address - City:HOLLYWOOD
Mailing Address - State:FL
Mailing Address - Zip Code:33019-5010
Mailing Address - Country:US
Mailing Address - Phone:954-589-8374
Mailing Address - Fax:
Practice Address - Street 1:17560 NW 27TH AVE STE 117
Practice Address - Street 2:
Practice Address - City:MIAMI GARDENS
Practice Address - State:FL
Practice Address - Zip Code:33056-4075
Practice Address - Country:US
Practice Address - Phone:305-623-5939
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-12-06
Last Update Date:2018-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCH12573111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor