Healthcare Provider Details

I. General information

NPI: 1700467370
Provider Name (Legal Business Name): INDEPENDENT BY DESIGN LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/15/2021
Last Update Date: 04/15/2021
Certification Date: 04/15/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1338 W SEASCAPE DR
GILBERT AZ
85233-5633
US

IV. Provider business mailing address

1338 W SEASCAPE DR
GILBERT AZ
85233-5633
US

V. Phone/Fax

Practice location:
  • Phone: 480-416-4675
  • Fax: 877-598-9763
Mailing address:
  • Phone: 480-416-4675
  • Fax: 877-598-9763

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code174400000X
TaxonomySpecialist
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code208100000X
TaxonomyPhysical Medicine & Rehabilitation Physician
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name: LORI DELABIO
Title or Position: OWNER
Credential:
Phone: 480-416-4675