Provider Demographics
NPI:1518344142
Name:ICON PROFESSIONAL SERVICES, INC.
Entity Type:Organization
Organization Name:ICON PROFESSIONAL SERVICES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:MS
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:
Authorized Official - Last Name:DUNCAN
Authorized Official - Suffix:
Authorized Official - Credentials:CRNFA
Authorized Official - Phone:469-248-0899
Mailing Address - Street 1:PO BOX 195249
Mailing Address - Street 2:
Mailing Address - City:DALLAS
Mailing Address - State:TX
Mailing Address - Zip Code:75219-8604
Mailing Address - Country:US
Mailing Address - Phone:469-248-0899
Mailing Address - Fax:210-547-9235
Practice Address - Street 1:11970 N CENTRAL EXPY
Practice Address - Street 2:SUITE 500
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75243-3768
Practice Address - Country:US
Practice Address - Phone:469-248-0899
Practice Address - Fax:210-547-9235
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-05-04
Last Update Date:2015-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA1903XAmbulatory Health Care FacilitiesClinic/CenterAmbulatory Surgical