Provider Demographics
NPI:1760258909
Name:ICONIC HOMECARE LLC
Entity Type:Organization
Organization Name:ICONIC HOMECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:AMANDA
Authorized Official - Middle Name:
Authorized Official - Last Name:EASTERLING
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:888-506-5336
Mailing Address - Street 1:PO BOX 728
Mailing Address - Street 2:
Mailing Address - City:BASSFIELD
Mailing Address - State:MS
Mailing Address - Zip Code:39421-0728
Mailing Address - Country:US
Mailing Address - Phone:888-506-5336
Mailing Address - Fax:662-593-0502
Practice Address - Street 1:270 HOSEY MIKELL RD
Practice Address - Street 2:
Practice Address - City:BASSFIELD
Practice Address - State:MS
Practice Address - Zip Code:39421
Practice Address - Country:US
Practice Address - Phone:888-506-5336
Practice Address - Fax:662-593-0502
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-11-29
Last Update Date:2023-11-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health