Provider Demographics
NPI:1942783162
Name:ICONIC MEDICAL TRANSPORTATION
Entity Type:Organization
Organization Name:ICONIC MEDICAL TRANSPORTATION
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:RENATA
Authorized Official - Middle Name:
Authorized Official - Last Name:WOMACK
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:225-424-3585
Mailing Address - Street 1:4775 LOIS DR
Mailing Address - Street 2:
Mailing Address - City:ZACHARY
Mailing Address - State:LA
Mailing Address - Zip Code:70791-3917
Mailing Address - Country:US
Mailing Address - Phone:225-424-3585
Mailing Address - Fax:
Practice Address - Street 1:4775 LOIS DR
Practice Address - Street 2:
Practice Address - City:ZACHARY
Practice Address - State:LA
Practice Address - Zip Code:70791-3917
Practice Address - Country:US
Practice Address - Phone:225-424-3585
Practice Address - Fax:225-570-2929
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-09-13
Last Update Date:2018-09-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)