Provider Demographics
NPI:1578279238
Name:ICONIQ SPINE & ORTHOPAEDIC CENTER PLLC
Entity Type:Organization
Organization Name:ICONIQ SPINE & ORTHOPAEDIC CENTER PLLC
Other - Org Name:HOLISTIQ SPINE & ORTHOPAEDIC CLINIC
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:
Authorized Official - First Name:TRUNG
Authorized Official - Middle Name:
Authorized Official - Last Name:HA
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:469-444-7246
Mailing Address - Street 1:4441 W AIRPORT FWY STE 215
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75062-5959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4441 W AIRPORT FWY STE 215
Practice Address - Street 2:
Practice Address - City:IRVING
Practice Address - State:TX
Practice Address - Zip Code:75062-5959
Practice Address - Country:US
Practice Address - Phone:469-444-7246
Practice Address - Fax:469-440-2667
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-01-26
Last Update Date:2024-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208VP0014XAllopathic & Osteopathic PhysiciansPain MedicineInterventional Pain MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Single Specialty
No332B00000XSuppliersDurable Medical Equipment & Medical SuppliesGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX1780936971OtherCASH