Healthcare Provider Details

I. General information

NPI: 1588610273
Provider Name (Legal Business Name): INDEPENDENCE, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/25/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 N SKYLINE, STE A 1230 N SKYLINE, STE A
IDAHO FALLS ID
83405
US

IV. Provider business mailing address

1230 N SKYLINE, STE A 1230 N SKYLINE, STE A
IDAHO FALLS ID
83405
US

V. Phone/Fax

Practice location:
  • Phone: 208-524-0881
  • Fax: 208-524-0886
Mailing address:
  • Phone: 208-524-0881
  • Fax: 208-524-0886

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code251B00000X
TaxonomyCase Management Agency
License Number
License Number StateID

VIII. Authorized Official

Name: MRS. DIANE ELAINE MOORE
Title or Position: ADMINISTRATOR
Credential: LSW
Phone: 208-524-0881