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General NPI Number Information
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NPI Number | 1942362165
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Entity Type | Organization
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Legal Business Name | ICON INDUSTRIES OF TEXAS, LLC
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Dates
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Enumeration Date | 12/14/2006
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Last Update Date | 08/22/2020
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Provider Practice Location Address
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Address Line | 443 BLUFF RIDGE RD
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City | WEATHERFORD
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State | TX
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Zip | 76087-1516
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Country | US
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Telephone | 817-881-7969
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Fax | 817-448-9083
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Provider Business Mailing Address
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Address Line | 443 BLUFF RIDGE RD
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City | WEATHERFORD
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State | TX
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Zip | 76087-1516
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Country | US
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Telephone | 817-881-7969
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Fax | 817-448-9083
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Authorized Official
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Title or Position | CEO
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Name | MR. BRETT SHELTON BRATCHER
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Credential | M.DIV., LNFA
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Telephone | 817-881-7969
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LG0600X
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Taxonomy Name | Gerontology Nurse Practitioner
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License Number |
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License Number State | TX
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