Provider Demographics
NPI:1194228643
Name:ICON PERFORMANCE PHYSICAL THERAPY
Entity Type:Organization
Organization Name:ICON PERFORMANCE PHYSICAL THERAPY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:CHARLES
Authorized Official - Middle Name:
Authorized Official - Last Name:HALL
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:205-259-3991
Mailing Address - Fax:205-876-8063
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:205-259-3991
Practice Address - Fax:205-876-8063
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-03-12
Last Update Date:2018-03-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistGroup - Single Specialty