Healthcare Provider Details

I. General information

NPI: 1215817895
Provider Name (Legal Business Name): ICENTIA, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/04/2025
Last Update Date: 10/06/2025
Certification Date: 10/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 MAIN ST STE 1W
BURLINGTON VT
05401-8581
US

IV. Provider business mailing address

106 MAIN ST STE 1W
BURLINGTON VT
05401-8581
US

V. Phone/Fax

Practice location:
  • Phone: 802-341-8696
  • Fax:
Mailing address:
  • Phone: 802-341-8696
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QR0208X
TaxonomyMobile Radiology Clinic/Center
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code293D00000X
TaxonomyPhysiological Laboratory
License Number
License Number State

VIII. Authorized Official

Name: YANNICK LEDEVEHAT
Title or Position: VICE PRESIDENT TECHNOLOGY
Credential:
Phone: 418-561-5926