MEDICARE: INDEPENDENT LIFE ANNEX

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	372600000X	Adult Companion
2	3104A0625X	Assisted Living Facility (Mental Illness)

General Provider Information

NPI Number	:	1831746643
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT LIFE ANNEX

Provider Business Mailing Address
First Line	:	PO BOX 155046
Second Line	:
City	:	IRVING
State	:	TX
Zip	:	75015-5046
Country	:	US
Telephone Number	:	469-712-4452
Fax Number	:

Provider Business Practice Location Address
First Line	:	6610 GREENSPRING DR
Second Line	:
City	:	ARLINGTON
State	:	TX
Zip	:	76016-5134
Country	:	US
Telephone Number	:	469-712-4452
Fax Number	:

Authorized Official
Title or Position	:	OWNER
Name	:	DEDRIC ASHLEY
Credential	:
Telephone Number	:	469-712-4452

Provider Enumeration Date	:	08/26/2019
Last Update Date	:	08/26/2019

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Directions to “INDEPENDENT LIFE ANNEX ” Practice Location

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