Provider Demographics
NPI:1154662278
Name:ICON PERFORMANCE
Entity Type:Organization
Organization Name:ICON PERFORMANCE
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CREDENTIALING MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:TERRI
Authorized Official - Middle Name:
Authorized Official - Last Name:CONNELL
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:205-259-3991
Mailing Address - Street 1:3156 SUNVIEW DR
Mailing Address - Street 2:
Mailing Address - City:VESTAVIA
Mailing Address - State:AL
Mailing Address - Zip Code:35243-5433
Mailing Address - Country:US
Mailing Address - Phone:205-939-2914
Mailing Address - Fax:
Practice Address - Street 1:3156 SUNVIEW DR
Practice Address - Street 2:
Practice Address - City:VESTAVIA
Practice Address - State:AL
Practice Address - Zip Code:35243-5433
Practice Address - Country:US
Practice Address - Phone:205-939-2914
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-03-14
Last Update Date:2013-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2251X0800XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistOrthopedicGroup - Multi-Specialty