Provider Demographics
NPI:1205268794
Name:ICONIC USA HEALTHCARE LLC
Entity type:Organization
Organization Name:ICONIC USA HEALTHCARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PARTNER
Authorized Official - Prefix:
Authorized Official - First Name:TAURA
Authorized Official - Middle Name:
Authorized Official - Last Name:STANSBERRY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:832-282-7511
Mailing Address - Street 1:6630 HORNWOOD DR
Mailing Address - Street 2:
Mailing Address - City:HOUSTON
Mailing Address - State:TX
Mailing Address - Zip Code:77074-5010
Mailing Address - Country:US
Mailing Address - Phone:832-497-5770
Mailing Address - Fax:888-294-7945
Practice Address - Street 1:6630 HORNWOOD DR
Practice Address - Street 2:
Practice Address - City:HOUSTON
Practice Address - State:TX
Practice Address - Zip Code:77074-5010
Practice Address - Country:US
Practice Address - Phone:832-497-5770
Practice Address - Fax:832-497-5771
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-08-06
Last Update Date:2013-12-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes208D00000XAllopathic & Osteopathic PhysiciansGeneral PracticeGroup - Multi-Specialty