Healthcare Provider Details

I. General information

NPI: 1861909707
Provider Name (Legal Business Name): ICE OPHTHALMOLOGY LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 12/31/2017
Last Update Date: 09/21/2020
Certification Date: 09/21/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2141 MENTOR AVE
PAINESVILLE OH
44077-1323
US

IV. Provider business mailing address

2141 MENTOR AVE
PAINESVILLE OH
44077-1323
US

V. Phone/Fax

Practice location:
  • Phone: 440-354-6900
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207W00000X
TaxonomyOphthalmology Physician
License Number09339
License Number StateOH

VIII. Authorized Official

Name: SEEMA ICE
Title or Position: OWNER
Credential: M.D.
Phone: 330-281-3009