Provider Demographics
NPI:1467281626
Name:ICOH LLC
Entity type:Organization
Organization Name:ICOH LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:
Authorized Official - First Name:KENYETTA
Authorized Official - Middle Name:L
Authorized Official - Last Name:DEAN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:260-602-3336
Mailing Address - Street 1:4919 PRIMITIVO PASS
Mailing Address - Street 2:
Mailing Address - City:FORT WAYNE
Mailing Address - State:IN
Mailing Address - Zip Code:46845-8759
Mailing Address - Country:US
Mailing Address - Phone:260-602-3336
Mailing Address - Fax:
Practice Address - Street 1:4919 PRIMITIVO PASS
Practice Address - Street 2:
Practice Address - City:FORT WAYNE
Practice Address - State:IN
Practice Address - Zip Code:46845-8759
Practice Address - Country:US
Practice Address - Phone:260-602-3336
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-07-29
Last Update Date:2024-07-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)