Healthcare Provider Details

I. General information

NPI: 1366202236
Provider Name (Legal Business Name): ICECARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/19/2024
Last Update Date: 03/19/2024
Certification Date: 03/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

976 MANSELL RD
ROSWELL GA
30076-1533
US

IV. Provider business mailing address

976 MANSELL RD
ROSWELL GA
30076-1533
US

V. Phone/Fax

Practice location:
  • Phone: 770-800-3277
  • Fax: 770-800-3537
Mailing address:
  • Phone: 770-800-3277
  • Fax: 770-800-3537

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 Code207RN0300X
TaxonomyNephrology Physician
License Number
License Number State

VIII. Authorized Official

Name: ANTHONY CHUKWUEMEKA C IWELUNMOR
Title or Position: MD
Credential: MD
Phone: 770-800-3277