Provider Demographics
NPI:1508021908
Name:ICEDOWN
Entity Type:Organization
Organization Name:ICEDOWN
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OFFICE ADMIN
Authorized Official - Prefix:
Authorized Official - First Name:PAULA
Authorized Official - Middle Name:
Authorized Official - Last Name:CAVANAUGH
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:909-307-8503
Mailing Address - Street 1:2232 VERUS ST
Mailing Address - Street 2:STE 2
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92154-4706
Mailing Address - Country:US
Mailing Address - Phone:909-307-8503
Mailing Address - Fax:909-307-8510
Practice Address - Street 1:2232 VERUS ST
Practice Address - Street 2:STE 2
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92154-4706
Practice Address - Country:US
Practice Address - Phone:909-307-8503
Practice Address - Fax:909-307-8510
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-07-24
Last Update Date:2008-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies