Healthcare Provider Details

I. General information

NPI: 1154212124
Provider Name (Legal Business Name): IC CAB LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/09/2025
Last Update Date: 07/09/2025
Certification Date: 07/09/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

500 MARKET ST STE 324
STEUBENVILLE OH
43952-2872
US

IV. Provider business mailing address

PO BOX 6878
WHEELING WV
26003-0924
US

V. Phone/Fax

Practice location:
  • Phone: 304-905-8249
  • Fax: 304-905-8251
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code344600000X
TaxonomyTaxi
License Number
License Number State

VIII. Authorized Official

Name: TATE BLANCHARD
Title or Position: CHIEF DEVELOPMENT DIRECTOR
Credential:
Phone: 304-905-8249