Provider Demographics
NPI:1366202236
Name:ICECARE LLC
Entity type:Organization
Organization Name:ICECARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MD
Authorized Official - Prefix:
Authorized Official - First Name:ANTHONY CHUKWUEMEKA
Authorized Official - Middle Name:C
Authorized Official - Last Name:IWELUNMOR
Authorized Official - Suffix:
Authorized Official - Credentials:MD
Authorized Official - Phone:770-800-3277
Mailing Address - Street 1:976 MANSELL RD
Mailing Address - Street 2:
Mailing Address - City:ROSWELL
Mailing Address - State:GA
Mailing Address - Zip Code:30076-1533
Mailing Address - Country:US
Mailing Address - Phone:770-800-3277
Mailing Address - Fax:770-800-3537
Practice Address - Street 1:976 MANSELL RD
Practice Address - Street 2:
Practice Address - City:ROSWELL
Practice Address - State:GA
Practice Address - Zip Code:30076-1533
Practice Address - Country:US
Practice Address - Phone:770-800-3277
Practice Address - Fax:770-800-3537
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-03-19
Last Update Date:2024-03-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
No207RN0300XAllopathic & Osteopathic PhysiciansInternal MedicineNephrologyGroup - Multi-Specialty