Healthcare Provider Details

I. General information

NPI: 1841939758
Provider Name (Legal Business Name): IC PROFESSIONAL SERVICES INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/31/2022
Last Update Date: 06/30/2026
Certification Date: 06/30/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4995 NW 72ND AVE STE 201
MIAMI FL
33166-5643
US

IV. Provider business mailing address

4995 NW 72ND AVE STE 201
MIAMI FL
33166-5643
US

V. Phone/Fax

Practice location:
  • Phone: 786-452-8963
  • Fax: 305-675-2727
Mailing address:
  • Phone: 786-452-8963
  • Fax: 305-675-2727

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code207R00000X
TaxonomyInternal Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: ILIANA CAMEJO
Title or Position: OWNER/APRN
Credential:
Phone: 305-978-2972