| Organization Name: | IVY MEDICAL CLINIC INC |
| NPI Number: | 1174934400 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | OMAR EDUARDO ESPINOSA (PRESIDENT/CEO) |
| Mailing Address: | 705 Ivy St Glendale |
| State: | CA US |
| Postal Code: | 91204 |
| Phone Number: | 8189455523 |
| Fax Number: | 8189455524 |
| NPI Enumeration Date: | 05/08/2014 |
| NPI Last Update Date: | 05/08/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 208D00000X |
| License Number: | A23122 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | CA |
| Taxonomy Type: | Allopathic & Osteopathic Physicians |
| Taxonomy Classification: | General Practice |
| Taxonomy Specialization: | |
| Taxonomy Definition: | |