Provider Demographics
NPI:1275124166
Name:ICARE CLINIC & MEDSPA LLC
Entity Type:Organization
Organization Name:ICARE CLINIC & MEDSPA LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:SIKIRAT
Authorized Official - Middle Name:
Authorized Official - Last Name:OROPO
Authorized Official - Suffix:
Authorized Official - Credentials:DNP
Authorized Official - Phone:770-856-8988
Mailing Address - Street 1:4580 MEMORIAL DR
Mailing Address - Street 2:
Mailing Address - City:DECATUR
Mailing Address - State:GA
Mailing Address - Zip Code:30032-1447
Mailing Address - Country:US
Mailing Address - Phone:404-963-6861
Mailing Address - Fax:404-963-6072
Practice Address - Street 1:4580 MEMORIAL DR
Practice Address - Street 2:
Practice Address - City:DECATUR
Practice Address - State:GA
Practice Address - Zip Code:30032-1447
Practice Address - Country:US
Practice Address - Phone:770-856-8988
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2021-02-02
Last Update Date:2024-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003246181AOther003246181A
GA734119526RMedicaid
GAG006535258OtherPTAN