Healthcare Provider Details

I. General information

NPI: 1508021908
Provider Name (Legal Business Name): ICEDOWN
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/24/2008
Last Update Date: 07/24/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2232 VERUS ST STE 2
SAN DIEGO CA
92154-4706
US

IV. Provider business mailing address

2232 VERUS ST STE 2
SAN DIEGO CA
92154-4706
US

V. Phone/Fax

Practice location:
  • Phone: 909-307-8503
  • Fax: 909-307-8510
Mailing address:
  • Phone: 909-307-8503
  • Fax: 909-307-8510

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: PAULA CAVANAUGH
Title or Position: OFFICE ADMIN
Credential:
Phone: 909-307-8503