Provider Demographics
NPI:1497369573
Name:IVY, CHARLES
Entity type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:IVY
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 1:4620 S VANDALIA AVE
Mailing Address - Street 2:
Mailing Address - City:TULSA
Mailing Address - State:OK
Mailing Address - Zip Code:74135-4715
Mailing Address - Country:US
Mailing Address - Phone:918-565-7151
Mailing Address - Fax:
Practice Address - Street 1:4620 S VANDALIA AVE
Practice Address - Street 2:
Practice Address - City:TULSA
Practice Address - State:OK
Practice Address - Zip Code:74135-4715
Practice Address - Country:US
Practice Address - Phone:918-565-7151
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-04
Last Update Date:2020-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator