Provider Demographics
NPI:1629212691
Name:ICE CAP REHAB, LLC
Entity type:Organization
Organization Name:ICE CAP REHAB, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MEMBER
Authorized Official - Prefix:
Authorized Official - First Name:JENNETH
Authorized Official - Middle Name:C
Authorized Official - Last Name:PANALIGAN
Authorized Official - Suffix:
Authorized Official - Credentials:RN
Authorized Official - Phone:630-369-8450
Mailing Address - Street 1:10451 W PALMERAS DR
Mailing Address - Street 2:SUITE 115
Mailing Address - City:SUN CITY
Mailing Address - State:AZ
Mailing Address - Zip Code:85373-2011
Mailing Address - Country:US
Mailing Address - Phone:623-933-1896
Mailing Address - Fax:623-933-4015
Practice Address - Street 1:10451 W PALMERAS DR
Practice Address - Street 2:SUITE 237W
Practice Address - City:SUN CITY
Practice Address - State:AZ
Practice Address - Zip Code:85373-2011
Practice Address - Country:US
Practice Address - Phone:623-933-1896
Practice Address - Fax:623-933-4015
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2009-04-22
Last Update Date:2009-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes261QR0400XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational TherapistGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ1629212691OtherBLUE CROSS BLUE SHIELD