Provider Demographics
NPI:1891522850
Name:IV-PROFUSION
Entity type:Organization
Organization Name:IV-PROFUSION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEDICAL DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:RONALD
Authorized Official - Middle Name:IRVING
Authorized Official - Last Name:JACOBY
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:626-260-3115
Mailing Address - Street 1:633 W ROUTE 66 APT 202
Mailing Address - Street 2:
Mailing Address - City:GLENDORA
Mailing Address - State:CA
Mailing Address - Zip Code:91740-4143
Mailing Address - Country:US
Mailing Address - Phone:626-260-3115
Mailing Address - Fax:
Practice Address - Street 1:655 W ARROW HWY UNIT 38
Practice Address - Street 2:
Practice Address - City:SAN DIMAS
Practice Address - State:CA
Practice Address - Zip Code:91773-2936
Practice Address - Country:US
Practice Address - Phone:626-260-3115
Practice Address - Fax:844-892-1555
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-09-16
Last Update Date:2024-09-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QI0500XAmbulatory Health Care FacilitiesClinic/CenterInfusion Therapy