Provider Demographics
NPI: | 1396374336 |
---|---|
Name: | IC COMMUNITY SERVICES CORP |
Entity Type: | Organization |
Organization Name: | IC COMMUNITY SERVICES CORP |
Other - Org Name: | |
Other - Org Type: | |
Authorized Official - Title/Position: | VICE PRESIDENT |
Authorized Official - Prefix: | |
Authorized Official - First Name: | BARBARA |
Authorized Official - Middle Name: | |
Authorized Official - Last Name: | GONZALEZ |
Authorized Official - Suffix: | |
Authorized Official - Credentials: | |
Authorized Official - Phone: | 305-846-9303 |
Mailing Address - Street 1: | 1968 S CONGRESS AVE |
Mailing Address - Street 2: | |
Mailing Address - City: | WEST PALM BEACH |
Mailing Address - State: | FL |
Mailing Address - Zip Code: | 33406-6674 |
Mailing Address - Country: | US |
Mailing Address - Phone: | 561-410-5433 |
Mailing Address - Fax: | |
Practice Address - Street 1: | 1968 S CONGRESS AVE |
Practice Address - Street 2: | |
Practice Address - City: | WEST PALM BEACH |
Practice Address - State: | FL |
Practice Address - Zip Code: | 33406-6674 |
Practice Address - Country: | US |
Practice Address - Phone: | 561-410-5433 |
Practice Address - Fax: | |
EIN: | <UNAVAIL> |
Is Organization Subpart?: | No |
Parent Organization LBN: | |
Parent Organization TIN: | |
Enumeration Date: | 2020-04-02 |
Last Update Date: | 2020-04-14 |
Deactivation Date: | |
Deactivation Code: | |
Reactivation Date: |
Provider Taxonomies
Primary? | Code | Type | Classification | Specialization |
---|---|---|---|---|
Yes | 261QM0801X | Ambulatory Health Care Facilities | Clinic/Center | Mental Health (Including Community Mental Health Center) |
No | 251B00000X | Agencies | Case Management |