Provider Demographics
NPI:1942362165
Name:ICON INDUSTRIES OF TEXAS, LLC
Entity Type:Organization
Organization Name:ICON INDUSTRIES OF TEXAS, LLC
Other - Org Name:LANDMARK PHYSICIANS GROUP
Other - Org Type:Doing Business As
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:BRETT
Authorized Official - Middle Name:SHELTON
Authorized Official - Last Name:BRATCHER
Authorized Official - Suffix:
Authorized Official - Credentials:MDIV, LNFA
Authorized Official - Phone:817-881-7969
Mailing Address - Street 1:443 BLUFF RIDGE RD
Mailing Address - Street 2:
Mailing Address - City:WEATHERFORD
Mailing Address - State:TX
Mailing Address - Zip Code:76087-1516
Mailing Address - Country:US
Mailing Address - Phone:817-881-7969
Mailing Address - Fax:817-448-9083
Practice Address - Street 1:443 BLUFF RIDGE RD
Practice Address - Street 2:
Practice Address - City:WEATHERFORD
Practice Address - State:TX
Practice Address - Zip Code:76087-1516
Practice Address - Country:US
Practice Address - Phone:817-881-7969
Practice Address - Fax:817-448-9083
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-14
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty