Provider Demographics
NPI:1013666304
Name:ICAN GROUP LLC
Entity Type:Organization
Organization Name:ICAN GROUP LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:DR
Authorized Official - First Name:MOHAMED
Authorized Official - Middle Name:
Authorized Official - Last Name:IMAM
Authorized Official - Suffix:
Authorized Official - Credentials:PHD
Authorized Official - Phone:480-267-0358
Mailing Address - Street 1:PO BOX 11716
Mailing Address - Street 2:
Mailing Address - City:TEMPE
Mailing Address - State:AZ
Mailing Address - Zip Code:85284-0029
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:911 E ORCHID LN
Practice Address - Street 2:
Practice Address - City:CHANDLER
Practice Address - State:AZ
Practice Address - Zip Code:85225-1406
Practice Address - Country:US
Practice Address - Phone:480-267-0358
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-03-22
Last Update Date:2022-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QA0600XAmbulatory Health Care FacilitiesClinic/CenterAdult Day Care