Individual
IVAN VICENTE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
IDMT
Contact information
Practice address
433 BLACK ELK CT, ELLSWORTH AFB, SD 57706-1847
(605) 521-3502
Mailing address
433 BLACK ELK CT, ELLSWORTH AFB, SD 57706-1847
(605) 521-3502
Taxonomy
Speciality
Code
Description
License number
State
1710I1003X
Independent Duty Medical Technicians
Primary
—
—
Other
Enumeration date
03/23/2010
Last updated
03/23/2010
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