Healthcare Provider Details

I. General information

NPI: 1841634201
Provider Name (Legal Business Name): ICE HEALTH SERVICE CORPS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/28/2013
Last Update Date: 04/28/2013
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3250 N PINAL PKWY
FLORENCE AZ
85132-9459
US

IV. Provider business mailing address

3250 N PINAL PKWY
FLORENCE AZ
85132-9459
US

V. Phone/Fax

Practice location:
  • Phone: 520-868-2049
  • Fax: 520-868-1547
Mailing address:
  • Phone: 520-868-2049
  • Fax: 520-868-1547

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QP0904X
TaxonomyFederal Public Health Clinic/Center
License Number0024169459
License Number StateVA

VIII. Authorized Official

Name: BRENT STEPHEN
Title or Position: HEALTH SERVICE ADMINISTRATOR
Credential:
Phone: 520-868-8439