MEDICARE: INDEPENDENT LIVING SUPPLIES, LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	332B00000X	Durable Medical Equipment & Medical Supplies

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1649270356
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT LIVING SUPPLIES, LLC

Provider Business Mailing Address
First Line	:	6100 W BLUEMOUND RD
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-4143
Country	:	US
Telephone Number	:	414-329-3962
Fax Number	:	414-329-3970

Provider Business Practice Location Address
First Line	:	6100 W BLUEMOUND RD
Second Line	:
City	:	WAUWATOSA
State	:	WI
Zip	:	53213-4143
Country	:	US
Telephone Number	:	414-329-3962
Fax Number	:	414-329-3970

Authorized Official
Title or Position	:	MEMBER
Name	:	MRS. ROXANNE L PETERSON
Credential	:
Telephone Number	:	414-329-3962

Provider Enumeration Date	:	07/22/2005
Last Update Date	:	01/02/2008

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