Provider Demographics
NPI:1457558520
Name:ICWM, LLC
Entity type:Organization
Organization Name:ICWM, LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:MR
Authorized Official - First Name:WALTER
Authorized Official - Middle Name:WILLARD
Authorized Official - Last Name:BALLARD
Authorized Official - Suffix:III
Authorized Official - Credentials:
Authorized Official - Phone:574-383-1751
Mailing Address - Street 1:PO BOX 10037
Mailing Address - Street 2:
Mailing Address - City:SOUTH BEND
Mailing Address - State:IN
Mailing Address - Zip Code:46680-0037
Mailing Address - Country:US
Mailing Address - Phone:574-287-7068
Mailing Address - Fax:574-287-7096
Practice Address - Street 1:59742 WREN LN
Practice Address - Street 2:
Practice Address - City:SOUTH BEND
Practice Address - State:IN
Practice Address - Zip Code:46614-4007
Practice Address - Country:US
Practice Address - Phone:574-231-1998
Practice Address - Fax:574-231-1997
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-06-30
Last Update Date:2008-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
INUSDOT 1427478 IN343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)