Healthcare Provider Details

I. General information

NPI: 1265545958
Provider Name (Legal Business Name): ICEBERG HEALTH CARE INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/16/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3631 CRENSHAW BLVD STE 111
LOS ANGELES CA
90016-4869
US

IV. Provider business mailing address

3631 CRENSHAW BLVD STE 111
LOS ANGELES CA
90016-4869
US

V. Phone/Fax

Practice location:
  • Phone: 323-733-5153
  • Fax: 323-733-5142
Mailing address:
  • Phone: 323-733-5153
  • Fax: 323-733-5142

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number StateCA

VIII. Authorized Official

Name: ANDERY YEVCHUK
Title or Position: PRESIDENT
Credential:
Phone: 323-733-5153