Provider Demographics
NPI:1205459864
Name:ICARUS MEDICAL, LLC.
Entity type:Organization
Organization Name:ICARUS MEDICAL, LLC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:CEO
Authorized Official - Prefix:MR
Authorized Official - First Name:DAVID
Authorized Official - Middle Name:T
Authorized Official - Last Name:JOHNSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:434-242-0258
Mailing Address - Street 1:609 E MARKET ST STE 114
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTESVILLE
Mailing Address - State:VA
Mailing Address - Zip Code:22902-5305
Mailing Address - Country:US
Mailing Address - Phone:888-492-1101
Mailing Address - Fax:434-270-7278
Practice Address - Street 1:609 E MARKET ST STE 114
Practice Address - Street 2:
Practice Address - City:CHARLOTTESVILLE
Practice Address - State:VA
Practice Address - Zip Code:22902-5305
Practice Address - Country:US
Practice Address - Phone:434-242-0258
Practice Address - Fax:434-270-7278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-18
Last Update Date:2024-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
No332BC3200XSuppliersDurable Medical Equipment & Medical SuppliesCustomized Equipment