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General NPI Number Information
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NPI Number | 1760258909
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Entity Type | Organization
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Legal Business Name | ICONIC HOMECARE LLC
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Dates
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Enumeration Date | 11/29/2023
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Last Update Date | 11/29/2023
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Provider Practice Location Address
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Address Line | 270 HOSEY MIKELL RD
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City | BASSFIELD
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State | MS
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Zip | 39421
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Country | US
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Telephone | 888-506-5336
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Fax | 662-593-0502
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Provider Business Mailing Address
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Address Line | PO BOX 728
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City | BASSFIELD
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State | MS
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Zip | 39421-0728
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Country | US
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Telephone | 888-506-5336
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Fax | 662-593-0502
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Authorized Official
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Title or Position | MANAGER
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Name | MRS. AMANDA EASTERLING
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Credential |
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Telephone | 888-506-5336
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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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