Healthcare Provider Details

I. General information

NPI: 1689839573
Provider Name (Legal Business Name): ICP&R ASSOCIATES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/21/2008
Last Update Date: 04/11/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1404 DEL PRADO BLVD S SUITE 110
CAPE CORAL FL
33990-3774
US

IV. Provider business mailing address

1404 DEL PRADO BLVD S SUITE 110
CAPE CORAL FL
33990-3774
US

V. Phone/Fax

Practice location:
  • Phone: 239-772-3232
  • Fax: 239-458-3272
Mailing address:
  • Phone: 239-772-3232
  • Fax: 239-458-3272

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code111N00000X
TaxonomyChiropractor
License NumberCH5040
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License NumberOS4407
License Number StateFL

VIII. Authorized Official

Name: DR. MARK A SMITH
Title or Position: PRESIDENT
Credential: D.C.
Phone: 239-772-3232