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Organization
ICP PPO, LLC
Active
Organization
ICP PPO, LLC
Active
Organization subpart
No
Provider details
NPI number
Authorized official
KELLY MACKEN - MARBLE (PRESIDENT)
(218) 393-1566
Entity
Organization
Contact information
Practice address
211 N EDDY ST, SOUTH BEND, IN 46617-2808
(574) 234-8161
Mailing address
413 W MONTGOMERY XRD STE 602, SAVANNAH, GA 31406-3396
(912) 691-5711
Taxonomy
Speciality
Code
Description
License number
State
174400000X
Specialist
—
—
305R00000X
Preferred Provider Organization
Primary
—
—
Other
Enumeration date
12/22/2020
Last updated
12/22/2020
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