| Organization Name: | ICONIC WELLNESS SURGICAL SERVICES |
| NPI Number: | 1316303035 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | SADYK FAYZULAYEV (MANAGING MEMBER) |
| Mailing Address: | 139 Harristown Rd Ste 205 Glen Rock |
| State: | NJ US |
| Postal Code: | 074523312 |
| Phone Number: | 2014441645 |
| Fax Number: | 2014441787 |
| NPI Enumeration Date: | 01/11/2016 |
| NPI Last Update Date: | 01/11/2016 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363AS0400X |
| License Number: | 25MP00262900 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | NJ |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Physician Assistant |
| Taxonomy Specialization: | Surgical |
| Taxonomy Definition: | |