MEDICARE: EPIC ICONIC HEALTH CARE LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	251C00000X	Developmentally Disabled Services Day Training Agency

General Provider Information

NPI Number	:	1366134330
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	EPIC ICONIC HEALTH CARE LLC

Provider Business Mailing Address
First Line	:	499 N STATE ROAD 434 STE 2179
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-1006
Country	:	US
Telephone Number	:	403-723-9658
Fax Number	:

Provider Business Practice Location Address
First Line	:	499 N STATE ROAD 434 STE 2179
Second Line	:
City	:	ALTAMONTE SPRINGS
State	:	FL
Zip	:	32714-1006
Country	:	US
Telephone Number	:	403-723-9658
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	SHELANDO DOWNER
Credential	:
Telephone Number	:	407-723-9658

Provider Enumeration Date	:	05/25/2023
Last Update Date	:	05/25/2023

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