Provider Demographics
NPI:1669722872
Name:ICAN CLINIC LLC
Entity type:Organization
Organization Name:ICAN CLINIC LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER/DIRECTOR
Authorized Official - Prefix:DR
Authorized Official - First Name:MICHAEL
Authorized Official - Middle Name:S
Authorized Official - Last Name:HARBISON
Authorized Official - Suffix:
Authorized Official - Credentials:DC
Authorized Official - Phone:618-254-2273
Mailing Address - Street 1:441 S STATE ROUTE 157 STE 102
Mailing Address - Street 2:
Mailing Address - City:EDWARDSVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:62025-4017
Mailing Address - Country:US
Mailing Address - Phone:618-254-2273
Mailing Address - Fax:618-254-8476
Practice Address - Street 1:441 S STATE ROUTE 157 STE 102
Practice Address - Street 2:
Practice Address - City:EDWARDSVILLE
Practice Address - State:IL
Practice Address - Zip Code:62025-4017
Practice Address - Country:US
Practice Address - Phone:618-254-2273
Practice Address - Fax:618-254-8476
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-09-14
Last Update Date:2022-08-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL038.12178111N00000X
111N00000X, 207Q00000X, 2081P2900X, 261QM1300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QM1300XAmbulatory Health Care FacilitiesClinic/CenterMulti-Specialty
No111N00000XChiropractic ProvidersChiropractorGroup - Single Specialty
No207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No2081P2900XAllopathic & Osteopathic PhysiciansPhysical Medicine & RehabilitationPain MedicineGroup - Multi-Specialty