Basic Information
| Provider Information | |||||||||
| NPI: | 1194228643 | ||||||||
| EntityType: | 2 | ||||||||
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| OrganizationName: | ICON PERFORMANCE PHYSICAL THERAPY | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3156 SUNVIEW DR | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352435433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052593991 | ||||||||
| FaxNumber: | 2058768063 | ||||||||
| Practice Location | |||||||||
| Address1: | 3156 SUNVIEW DR | ||||||||
| Address2: | |||||||||
| City: | VESTAVIA | ||||||||
| State: | AL | ||||||||
| PostalCode: | 352435433 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2052593991 | ||||||||
| FaxNumber: | 2058768063 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/12/2018 | ||||||||
| LastUpdateDate: | 03/12/2018 | ||||||||
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| AuthorizedOfficialLastName: | HALL | ||||||||
| AuthorizedOfficialFirstName: | CHARLES | ||||||||
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| AuthorizedOfficialTitleorPosition: | MEMBER | ||||||||
| AuthorizedOfficialTelephone: | 2052593991 | ||||||||
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| IsOrganizationSubpart: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 225100000X | Y | 193400000X SINGLE SPECIALTY GROUP | Respiratory, Developmental, Rehabilitative and Restorative Service Providers | Physical Therapist |
No ID Information.