Healthcare Provider Details

I. General information

NPI: 1205459864
Provider Name (Legal Business Name): ICARUS MEDICAL, LLC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/18/2020
Last Update Date: 05/01/2024
Certification Date: 05/01/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

609 E MARKET ST STE 114
CHARLOTTESVILLE VA
22902-5305
US

IV. Provider business mailing address

609 E MARKET ST STE 114
CHARLOTTESVILLE VA
22902-5305
US

V. Phone/Fax

Practice location:
  • Phone: 434-242-0258
  • Fax: 434-270-7278
Mailing address:
  • Phone: 888-492-1101
  • Fax: 434-270-7278

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code332B00000X
TaxonomyDurable Medical Equipment & Medical Supplies
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code332BC3200X
TaxonomyCustomized Equipment (DME)
License Number
License Number State

VIII. Authorized Official

Name: MR. DAVID T JOHNSON
Title or Position: CEO
Credential:
Phone: 434-242-0258