Basic Information
| Provider Information | |||||||||
| NPI: | 1952663445 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | IRIARTE | ||||||||
| FirstName: | ILVA | ||||||||
| MiddleName: | GENOVEVA | ||||||||
| NamePrefix: | DR. | ||||||||
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| Mailing Information | |||||||||
| Address1: | 125 E CHEVES ST | ||||||||
| Address2: | |||||||||
| City: | FLORENCE | ||||||||
| State: | SC | ||||||||
| PostalCode: | 295062526 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8436292494 | ||||||||
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| Practice Location | |||||||||
| Address1: | 2100 CHARLIE HALL BLVD | ||||||||
| Address2: | |||||||||
| City: | CHARLESTON | ||||||||
| State: | SC | ||||||||
| PostalCode: | 294145832 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8438524100 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/12/2012 | ||||||||
| LastUpdateDate: | 10/30/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 2084P0800X | LL34775 | SC | N | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry | 2084P0800X | MD34775 | SC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
ID Information
| ID | Type | State | Issuer | Description | 1760596480 | 05 | SC | MEDICAID |