=====================================================
General NPI Number Information
=====================================================
NPI Number | 1093631129
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ICONIC DME LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/24/2026
-----------------------------------------------------
Last Update Date | 06/24/2026
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1600 PROVIDENCE HWY
-----------------------------------------------------
City | WALPOLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02081-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-446-4118
-----------------------------------------------------
Fax | 888-804-0426
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1600 PROVIDENCE HWY
-----------------------------------------------------
City | WALPOLE
-----------------------------------------------------
State | MA
-----------------------------------------------------
Zip | 02081-2553
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 888-446-4118
-----------------------------------------------------
Fax | 888-804-0426
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | DANIEL WHITE
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 888-446-4118
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------