Healthcare Provider Details

I. General information

NPI: 1184016032
Provider Name (Legal Business Name): ICB ENTERPRISES CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/02/2015
Last Update Date: 02/19/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11183 CIRCLE DR SUITE C
AUSTIN TX
78736
US

IV. Provider business mailing address

11183 CIRCLE C DR SUITE C
AUSTIN TX
78736
US

V. Phone/Fax

Practice location:
  • Phone: 512-400-2333
  • Fax: 512-400-2334
Mailing address:
  • Phone: 512-400-2333
  • Fax: 512-400-2334

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number016857
License Number StateTX
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateTX
# 4
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateTX

VIII. Authorized Official

Name: MR. RAPHAEL HERNANDEZ
Title or Position: ADMINISTRATOR
Credential:
Phone: 512-400-2333