MEDICARE: ICEESHO BETHEL RRT

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2278G0305X	Geriatric Care Certified Respiratory Therapist	7058	GA
2	2278H0200X	Home Health Certified Respiratory Therapist	7058	GA

General Provider Information

NPI Number	:	1619227576
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ICEESHO BETHEL RRT

Provider Business Mailing Address
First Line	:	2086 JODECO RD # 1674
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-5220
Country	:	US
Telephone Number	:	678-763-9797
Fax Number	:

Provider Business Practice Location Address
First Line	:	2086 JODECO RD # 1674
Second Line	:
City	:	MCDONOUGH
State	:	GA
Zip	:	30253-5220
Country	:	US
Telephone Number	:	678-763-9797
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/18/2012
Last Update Date	:	03/23/2026

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