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General NPI Number Information
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NPI Number | 1205148079
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Entity Type | Organization
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Legal Business Name | ICONIC HEALTHCARE SERVICES CO.
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Dates
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Enumeration Date | 07/09/2010
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Last Update Date | 08/07/2012
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Provider Practice Location Address
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Address Line | 17045 EL CAMINO REAL STE 218
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City | HOUSTON
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State | TX
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Zip | 77058-2644
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Country | US
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Telephone | 281-461-4000
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Fax | 281-204-9040
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Provider Business Mailing Address
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Address Line | 17045 EL CAMINO REAL, SUITE 218
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City | HOUSTON
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State | TX
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Zip | 77058
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position | PRESIDENT/CEO
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Name | DR. WILFRED USI AJAYI
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Credential | MD., PHD.
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Telephone | 281-901-8950
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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