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General NPI Number Information
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NPI Number | 1689563405
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Entity Type | Organization
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Legal Business Name | ICONIC HUMAN DESIGN, LLC
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Dates
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Enumeration Date | 06/30/2025
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Last Update Date | 06/30/2025
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Provider Practice Location Address
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Address Line | 180 S MERRITT RANCH RD
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City | CORNVILLE
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State | AZ
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Zip | 86325-5733
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Country | US
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Telephone | 928-848-7388
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Fax |
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Provider Business Mailing Address
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Address Line | 1771 W ST RTE 89A STE 2516
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City | SEDONA
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State | AZ
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Zip | 86336-5594
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Country | US
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Telephone | 928-948-7388
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Fax |
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Authorized Official
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Title or Position | MEMBER MANAGER
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Name | LAVEENA BRIANNE ARCHERS
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Credential | PHD
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Telephone | 928-948-7388
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 174200000X
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Taxonomy Name | Meals Provider
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License Number |
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License Number State |
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