Provider Demographics
NPI:1295595379
Name:PARK IVY CONSULTANTS, INC
Entity type:Organization
Organization Name:PARK IVY CONSULTANTS, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:SEC/TREASURER
Authorized Official - Prefix:MR
Authorized Official - First Name:JERRY
Authorized Official - Middle Name:DALE
Authorized Official - Last Name:FREDERIKSEN
Authorized Official - Suffix:SR
Authorized Official - Credentials:
Authorized Official - Phone:479-459-6354
Mailing Address - Street 1:PO BOX 6691
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-0601
Mailing Address - Country:US
Mailing Address - Phone:479-459-6354
Mailing Address - Fax:479-459-6354
Practice Address - Street 1:5123 FIGURE FIVE HTS
Practice Address - Street 2:
Practice Address - City:RUDY
Practice Address - State:AR
Practice Address - Zip Code:72952-9417
Practice Address - Country:US
Practice Address - Phone:479-459-6354
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care