Provider Demographics
NPI:1659090934
Name:ICON CLINIC LLC
Entity Type:Organization
Organization Name:ICON CLINIC LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER OF ENTITY
Authorized Official - Prefix:
Authorized Official - First Name:THICKNESS
Authorized Official - Middle Name:PATRICK
Authorized Official - Last Name:EGWUATU
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:202-288-7752
Mailing Address - Street 1:7735 BELLE POINT DR
Mailing Address - Street 2:
Mailing Address - City:GREENBELT
Mailing Address - State:MD
Mailing Address - Zip Code:20770-3300
Mailing Address - Country:US
Mailing Address - Phone:240-455-3166
Mailing Address - Fax:
Practice Address - Street 1:7735 BELLE POINT DR
Practice Address - Street 2:
Practice Address - City:GREENBELT
Practice Address - State:MD
Practice Address - Zip Code:20770-3300
Practice Address - Country:US
Practice Address - Phone:240-455-3166
Practice Address - Fax:240-455-4154
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-08-22
Last Update Date:2022-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QM0801XAmbulatory Health Care FacilitiesClinic/CenterMental Health (Including Community Mental Health Center)