Healthcare Provider Details

I. General information

NPI: 1609547686
Provider Name (Legal Business Name): ICON COSMETIC CENTER LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/21/2021
Last Update Date: 09/21/2021
Certification Date: 09/21/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

8930 W SUNSET RD STE 140
LAS VEGAS NV
89148-5009
US

IV. Provider business mailing address

8930 W SUNSET RD STE 140
LAS VEGAS NV
89148-5009
US

V. Phone/Fax

Practice location:
  • Phone: 702-703-3040
  • Fax:
Mailing address:
  • Phone: 702-703-3040
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2086S0122X
TaxonomyPlastic and Reconstructive Surgery Physician
License Number
License Number State

VIII. Authorized Official

Name: ADAHLIA ALCOVA
Title or Position: GENERAL MANAGER
Credential:
Phone: 702-964-4779