MEDICARE: ICON NEUROMONITORING, 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	246ZE0500X	EEG Specialist/Technologist
2	246ZE0600X	Electroneurodiagnostic Specialist/Technologist

General Provider Information

NPI Number	:	1750867123
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICON NEUROMONITORING, LLC

Provider Business Mailing Address
First Line	:	23742 ARDMORE COVE DR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77386-4255
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	23742 ARDMORE COVE DR
Second Line	:
City	:	SPRING
State	:	TX
Zip	:	77386-4255
Country	:	US
Telephone Number	:	832-385-5218
Fax Number	:

Authorized Official
Title or Position	:	MANAGER
Name	:	MRS. LISA GARCIA
Credential	:
Telephone Number	:	832-385-5218

Provider Enumeration Date	:	07/18/2018
Last Update Date	:	07/18/2018

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