Provider Demographics
NPI:1568992352
Name:ICARE PEDIATRIC & ADULT THERAPY LLC
Entity Type:Organization
Organization Name:ICARE PEDIATRIC & ADULT THERAPY LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO, OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:CARLA
Authorized Official - Middle Name:JO
Authorized Official - Last Name:MOON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:903-908-3839
Mailing Address - Street 1:4062 SUMMERHILL SQ
Mailing Address - Street 2:
Mailing Address - City:TEXARKANA
Mailing Address - State:TX
Mailing Address - Zip Code:75503-2730
Mailing Address - Country:US
Mailing Address - Phone:903-908-3839
Mailing Address - Fax:
Practice Address - Street 1:4062 SUMMERHILL SQ
Practice Address - Street 2:
Practice Address - City:TEXARKANA
Practice Address - State:TX
Practice Address - Zip Code:75503-2730
Practice Address - Country:US
Practice Address - Phone:903-908-3839
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2017-06-14
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1268067261QP2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2000XAmbulatory Health Care FacilitiesClinic/CenterPhysical Therapy