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General NPI Number Information
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NPI Number | 1831789338
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Entity Type | Organization
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Legal Business Name | ICONIC MEDICAL AND WELLNESS CENTERS
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Dates
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Enumeration Date | 01/19/2021
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Last Update Date | 01/19/2021
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Provider Practice Location Address
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Address Line | 5 COLD HILL RD S STE 26J
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City | MENDHAM
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State | NJ
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Zip | 07945-3208
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Country | US
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Telephone | 973-531-6377
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Fax |
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Provider Business Mailing Address
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Address Line | 5 COLD HILL RD S STE 26J
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City | MENDHAM
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State | NJ
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Zip | 07945-3208
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Country | US
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Telephone | 973-531-6377
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Fax |
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Authorized Official
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Title or Position | PHYSICIAN ASSISTANT
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Name | MARIA KOROGODSKY
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Credential | PA-C
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Telephone | 908-403-1160
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261QH0100X
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Taxonomy Name | Health Service Clinic/Center
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License Number |
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License Number State |
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