Provider Demographics
NPI:1609547686
Name:ICON COSMETIC CENTER LLC
Entity Type:Organization
Organization Name:ICON COSMETIC CENTER LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:GENERAL MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:ADAHLIA
Authorized Official - Middle Name:
Authorized Official - Last Name:ALCOVA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:702-964-4779
Mailing Address - Street 1:8930 W SUNSET RD STE 140
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89148-5009
Mailing Address - Country:US
Mailing Address - Phone:702-703-3040
Mailing Address - Fax:
Practice Address - Street 1:8930 W SUNSET RD STE 140
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89148-5009
Practice Address - Country:US
Practice Address - Phone:702-703-3040
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-09-21
Last Update Date:2021-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes2086S0122XAllopathic & Osteopathic PhysiciansSurgeryPlastic and Reconstructive SurgeryGroup - Single Specialty