Provider Demographics
NPI:1073108692
Name:ICON MEDICAL CENTERS, LLC
Entity Type:Organization
Organization Name:ICON MEDICAL CENTERS, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:EDWARD
Authorized Official - Middle Name:J
Authorized Official - Last Name:LUCAS
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:352-694-6331
Mailing Address - Street 1:232 SW 8TH ST
Mailing Address - Street 2:
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33130-3514
Mailing Address - Country:US
Mailing Address - Phone:305-858-8845
Mailing Address - Fax:352-694-6338
Practice Address - Street 1:3625 HOLLYWOOD BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:FL
Practice Address - Zip Code:33021-6854
Practice Address - Country:US
Practice Address - Phone:954-987-8400
Practice Address - Fax:352-694-6338
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:ICON MEDICAL CENTERS, LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2021-03-05
Last Update Date:2021-03-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes111N00000XChiropractic ProvidersChiropractorGroup - Multi-Specialty