Healthcare Provider Details

I. General information

NPI: 1376798009
Provider Name (Legal Business Name): INDEPENDENT LIFE SERVICES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/21/2008
Last Update Date: 11/21/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3641 E SOUTHERN AVE
MESA AZ
85206-2503
US

IV. Provider business mailing address

3641 E SOUTHERN AVE
MESA AZ
85206-2503
US

V. Phone/Fax

Practice location:
  • Phone: 480-917-2034
  • Fax: 480-917-2115
Mailing address:
  • Phone: 480-917-2034
  • Fax: 480-917-2115

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: TYLER BURKE
Title or Position: PRESIDENT
Credential:
Phone: 480-917-2034