MEDICARE: ICE HEALTH SERVICE CORPS

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	261QP0904X	Federal Public Health Clinic/Center	0024169459	VA

General Provider Information

NPI Number	:	1841634201
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICE HEALTH SERVICE CORPS

Provider Business Mailing Address
First Line	:	3250 N PINAL PKWY
Second Line	:
City	:	FLORENCE
State	:	AZ
Zip	:	85132-9459
Country	:	US
Telephone Number	:	520-868-2049
Fax Number	:	520-868-1547

Provider Business Practice Location Address
First Line	:	3250 N PINAL PKWY
Second Line	:
City	:	FLORENCE
State	:	AZ
Zip	:	85132-9459
Country	:	US
Telephone Number	:	520-868-2049
Fax Number	:	520-868-1547

Authorized Official
Title or Position	:	HEALTH SERVICE ADMINISTRATOR
Name	:	BRENT STEPHEN
Credential	:
Telephone Number	:	520-868-8439

Provider Enumeration Date	:	04/28/2013
Last Update Date	:	04/28/2013

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Directions to “ICE HEALTH SERVICE CORPS ” Practice Location

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