NPI 1407443617

Icp Ppo, LLC

Organisation Preferred Provider Organization South Bend, IN

Practice location

Address: 211 N Eddy St, South Bend, IN 46617-2808
Phone: (574) 234-8161
Mailing address: 413 W Montgomery Xrd STE 602, Savannah, GA 31406-3396

Authorised official

Name: Kelly Macken - Marble
Title: President
Phone: (218) 393-1566

Registered specialties (2)

Preferred Provider Organization Primary

Managed Care Organizations Taxonomy 305R00000X

Other Preferred Provider Organization providers in Indiana →

Specialist

Other Service Providers Taxonomy 174400000X

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Registry record

NPI: 1407443617
Entity type: Organization
NPI issued: 22 Dec 2020
Record last updated: 22 Dec 2020

Reproduced from NPPES, the federal provider registry. The date above is when the provider last updated their own entry, not when we fetched it - a record can be years old and still current in the registry.