Provider Demographics
NPI:1255511499
Name:ICON MED TECH CORPORATION
Entity type:Organization
Organization Name:ICON MED TECH CORPORATION
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:GUSTAVO
Authorized Official - Middle Name:ADOLFO
Authorized Official - Last Name:GARCIA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:305-222-9164
Mailing Address - Street 1:175 FONTAINEBLEAU BLVD
Mailing Address - Street 2:2 K 6
Mailing Address - City:MIAMI
Mailing Address - State:FL
Mailing Address - Zip Code:33172-7018
Mailing Address - Country:US
Mailing Address - Phone:305-222-9164
Mailing Address - Fax:
Practice Address - Street 1:175 FONTAINEBLEAU BLVD
Practice Address - Street 2:2 K 6
Practice Address - City:MIAMI
Practice Address - State:FL
Practice Address - Zip Code:33172
Practice Address - Country:US
Practice Address - Phone:305-222-9164
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-11-05
Last Update Date:2008-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies