Provider Demographics
NPI:1841634201
Name:ICE HEALTH SERVICE CORPS
Entity type:Organization
Organization Name:ICE HEALTH SERVICE CORPS
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:HEALTH SERVICE ADMINISTRATOR
Authorized Official - Prefix:
Authorized Official - First Name:BRENT
Authorized Official - Middle Name:
Authorized Official - Last Name:STEPHEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:520-868-8439
Mailing Address - Street 1:3250 N PINAL PKWY
Mailing Address - Street 2:
Mailing Address - City:FLORENCE
Mailing Address - State:AZ
Mailing Address - Zip Code:85132-9459
Mailing Address - Country:US
Mailing Address - Phone:520-868-2049
Mailing Address - Fax:520-868-1547
Practice Address - Street 1:3250 N PINAL PKWY
Practice Address - Street 2:
Practice Address - City:FLORENCE
Practice Address - State:AZ
Practice Address - Zip Code:85132-9459
Practice Address - Country:US
Practice Address - Phone:520-868-2049
Practice Address - Fax:520-868-1547
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-04-28
Last Update Date:2013-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024169459261QP0904X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QP0904XAmbulatory Health Care FacilitiesClinic/CenterPublic Health, Federal