Provider Demographics
NPI:1164288809
Name:ICARUS HOUSE LLC.
Entity Type:Organization
Organization Name:ICARUS HOUSE LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO/MANGER
Authorized Official - Prefix:
Authorized Official - First Name:DONATUS
Authorized Official - Middle Name:
Authorized Official - Last Name:AGBAKWU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:310-621-2776
Mailing Address - Street 1:1721 W MAGDALENA LN
Mailing Address - Street 2:
Mailing Address - City:PHOENIX
Mailing Address - State:AZ
Mailing Address - Zip Code:85041-7814
Mailing Address - Country:US
Mailing Address - Phone:310-621-2776
Mailing Address - Fax:
Practice Address - Street 1:23832 W TONTO ST
Practice Address - Street 2:
Practice Address - City:BUCKEYE
Practice Address - State:AZ
Practice Address - Zip Code:85326-8139
Practice Address - Country:US
Practice Address - Phone:310-621-2776
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-02-21
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251S00000XAgenciesCommunity/Behavioral Health