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NPI Code Detail

MEDICARE: ICE CAP REHAB, LLC

MEDICARE: ICE CAP REHAB, 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
1225X00000XOccupational Therapist
2261QR0400XRehabilitation Clinic/Center

Other Identifiers

# Provider Identifier Provider Identifier Type Provider Identifier State Provider Identifier Issuer
11629212691OTHERAZBLUE CROSS BLUE SHIELD

General Provider Information

NPI Number : 1629212691
Entity Type Code : Organization
Provider Name (Legal Business Name) : ICE CAP REHAB, LLC
Provider Business Mailing Address
First Line : 10451 W PALMERAS DR
Second Line : SUITE 115
City : SUN CITY
State : AZ
Zip : 85373-2011
Country : US
Telephone Number : 623-933-1896
Fax Number : 623-933-4015
Provider Business Practice Location Address
First Line : 10451 W PALMERAS DR
Second Line : SUITE 237W
City : SUN CITY
State : AZ
Zip : 85373-2011
Country : US
Telephone Number : 623-933-1896
Fax Number : 623-933-4015
Authorized Official
Title or Position : MEMBER
Name : JENNETH C PANALIGAN
Credential : RN
Telephone Number : 630-369-8450
Provider Enumeration Date : 04/22/2009
Last Update Date : 11/18/2009

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