MEDICARE: INDEPENDENCE REHABILITATION SERVICES INC.

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	225XP0200X	Pediatric Occupational Therapist	1237	NC

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	:	1679613434
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENCE REHABILITATION SERVICES INC.

Provider Business Mailing Address
First Line	:	3109 WICKFORD DR
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28409-8531
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3109 WICKFORD DR
Second Line	:
City	:	WILMINGTON
State	:	NC
Zip	:	28409-8531
Country	:	US
Telephone Number	:	910-790-2869
Fax Number	:

Authorized Official
Title or Position	:	PRESIDENT
Name	:	MICHELLE WILLIS
Credential	:
Telephone Number	:	910-297-6067

Provider Enumeration Date	:	02/08/2007
Last Update Date	:	08/22/2020

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