Provider Demographics
NPI:1205148079
Name:ICONIC HEALTHCARE SERVICES CO.
Entity type:Organization
Organization Name:ICONIC HEALTHCARE SERVICES CO.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT/CEO
Authorized Official - Prefix:DR
Authorized Official - First Name:WILFRED
Authorized Official - Middle Name:USI
Authorized Official - Last Name:AJAYI
Authorized Official - Suffix:
Authorized Official - Credentials:MD, PHD
Authorized Official - Phone:281-901-8950
Mailing Address - Street 1:17045 EL CAMINO REAL, SUITE 218
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77058
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17045 EL CAMINO REAL STE 218
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77058-2644
Practice Address - Country:US
Practice Address - Phone:281-461-4000
Practice Address - Fax:281-204-9040
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2010-07-09
Last Update Date:2012-08-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX289023801Medicaid