Healthcare Provider Details

I. General information

NPI: 1194228643
Provider Name (Legal Business Name): ICON PERFORMANCE PHYSICAL THERAPY
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/12/2018
Last Update Date: 03/12/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3156 SUNVIEW DR
VESTAVIA AL
35243-5433
US

IV. Provider business mailing address

3156 SUNVIEW DR
VESTAVIA AL
35243-5433
US

V. Phone/Fax

Practice location:
  • Phone: 205-259-3991
  • Fax: 205-876-8063
Mailing address:
  • Phone: 205-259-3991
  • Fax: 205-876-8063

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code225100000X
TaxonomyPhysical Therapist
License Number
License Number State

VIII. Authorized Official

Name: CHARLES HALL
Title or Position: MEMBER
Credential:
Phone: 205-259-3991