Provider Demographics
NPI:1750872354
Name:ICONIC SERVICES INC
Entity type:Organization
Organization Name:ICONIC SERVICES INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:CHRISTINE
Authorized Official - Middle Name:B
Authorized Official - Last Name:CORDERO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:314-437-8932
Mailing Address - Street 1:4625 LINDELL BLVD STE 200
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63108-3729
Mailing Address - Country:US
Mailing Address - Phone:314-437-8932
Mailing Address - Fax:888-749-2228
Practice Address - Street 1:4625 LINDELL BLVD STE 200
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63108-3729
Practice Address - Country:US
Practice Address - Phone:314-437-8932
Practice Address - Fax:888-749-2228
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-21
Last Update Date:2018-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207QS0010XAllopathic & Osteopathic PhysiciansFamily MedicineSports MedicineGroup - Single Specialty