1629212691 NPI number — ICE CAP REHAB, LLC

Table of content: (NPI 1629212691)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1629212691 NPI number — ICE CAP REHAB, LLC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
ICE CAP REHAB, LLC
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1629212691
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/18/2009
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
10451 W PALMERAS DR
Provider Second Line Business Mailing Address:
SUITE 115
Provider Business Mailing Address City Name:
SUN CITY
Provider Business Mailing Address State Name:
AZ
Provider Business Mailing Address Postal Code:
85373-2011
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
623-933-1896
Provider Business Mailing Address Fax Number:
623-933-4015

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
10451 W PALMERAS DR
Provider Second Line Business Practice Location Address:
SUITE 237W
Provider Business Practice Location Address City Name:
SUN CITY
Provider Business Practice Location Address State Name:
AZ
Provider Business Practice Location Address Postal Code:
85373-2011
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
623-933-1896
Provider Business Practice Location Address Fax Number:
623-933-4015
Provider Enumeration Date:
04/22/2009

Additional Information

Authorized Official

Authorized Official Last Name:
PANALIGAN
Authorized Official First Name:
JENNETH
Authorized Official Middle Name:
C
Authorized Official Title or Position:
MEMBER
Authorized Official Telephone Number:
630-369-8450

Provider Taxonomy Codes

  • Taxonomy code: 225X00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QR0400X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 1629212691 . This is a "BLUE CROSS BLUE SHIELD" identifier , issued by the state of ( AZ ) . This identifiers is of the category "OTHER".




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