MEDICARE: ICONIC MEDICAL SUPPLIES AND SERVICES INC

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	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1912612425
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	ICONIC MEDICAL SUPPLIES AND SERVICES INC

Provider Business Mailing Address
First Line	:	1860 FOREST HILL BLVD STE 204
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-6086
Country	:	US
Telephone Number	:	561-541-8586
Fax Number	:

Provider Business Practice Location Address
First Line	:	1860 FOREST HILL BLVD STE 204
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33406-6086
Country	:	US
Telephone Number	:	561-541-8586
Fax Number	:

Authorized Official
Title or Position	:	OWNER/PRESIDENT
Name	:	MS. CARRA RUSSELL
Credential	:
Telephone Number	:	561-541-8586

Provider Enumeration Date	:	01/18/2023
Last Update Date	:	07/03/2024

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