Provider Demographics
NPI:1871045492
Name:ICON IMAGING LLC
Entity Type:Organization
Organization Name:ICON IMAGING LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:FAUSTO
Authorized Official - Middle Name:L
Authorized Official - Last Name:MINAYA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:203-553-9696
Mailing Address - Street 1:PO BOX 566
Mailing Address - Street 2:
Mailing Address - City:ORANGE
Mailing Address - State:CT
Mailing Address - Zip Code:06477-0566
Mailing Address - Country:US
Mailing Address - Phone:203-553-9696
Mailing Address - Fax:
Practice Address - Street 1:540 BISHOP DR
Practice Address - Street 2:
Practice Address - City:ORANGE
Practice Address - State:CT
Practice Address - Zip Code:06477-2522
Practice Address - Country:US
Practice Address - Phone:203-553-9696
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2016-10-31
Last Update Date:2016-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0208XAmbulatory Health Care FacilitiesClinic/CenterRadiology, Mobile