Provider Demographics
NPI:1629756929
Name:ICDOC LLC
Entity Type:Organization
Organization Name:ICDOC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER, ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:SHELLY
Authorized Official - Middle Name:
Authorized Official - Last Name:GRESHAM
Authorized Official - Suffix:
Authorized Official - Credentials:RN, NP-C
Authorized Official - Phone:573-776-0157
Mailing Address - Street 1:2445 N WESTWOOD BLVD STE 100
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-2317
Mailing Address - Country:US
Mailing Address - Phone:573-776-0157
Mailing Address - Fax:
Practice Address - Street 1:2445 N WESTWOOD BLVD STE 100
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901-2317
Practice Address - Country:US
Practice Address - Phone:573-776-0157
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-07-06
Last Update Date:2023-07-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP2300XAmbulatory Health Care FacilitiesClinic/CenterPrimary Care