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General NPI Number Information
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NPI Number | 1316303035
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Entity Type | Organization
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Legal Business Name | ICONIC WELLNESS SURGICAL SERVICES
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Dates
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Enumeration Date | 01/11/2016
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Last Update Date | 01/11/2016
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Provider Practice Location Address
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Address Line | 139 HARRISTOWN RD STE 205
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City | GLEN ROCK
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State | NJ
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Zip | 07452-3312
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Country | US
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Telephone | 201-444-1645
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Fax | 201-444-1787
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Provider Business Mailing Address
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Address Line | 139 HARRISTOWN RD STE 205
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City | GLEN ROCK
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State | NJ
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Zip | 07452-3312
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Country | US
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Telephone | 201-444-1645
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Fax | 201-444-1787
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Authorized Official
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Title or Position | MANAGING MEMBER
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Name | MR. SADYK FAYZULAYEV
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Credential | PA
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Telephone | 201-444-1645
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363AS0400X
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Taxonomy Name | Surgical Physician Assistant
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License Number | 25MP00262900
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License Number State | NJ
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