Healthcare Provider Details

I. General information

NPI: 1801380001
Provider Name (Legal Business Name): ICP ALABAMA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/20/2018
Last Update Date: 12/18/2020
Certification Date: 12/18/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2700 CORPORATE DR STE 200
BIRMINGHAM AL
35242-2733
US

IV. Provider business mailing address

PO BOX 9178
RUSSELLVILLE AR
72811-9178
US

V. Phone/Fax

Practice location:
  • Phone: 855-498-6767
  • Fax: 479-968-1673
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: RODNEY THOMASON
Title or Position: AUTHORIZED OFFICIAL
Credential:
Phone: 479-498-6747