Healthcare Provider Details

I. General information

NPI: 1770742801
Provider Name (Legal Business Name): INDEPENDENCE HEALTHCARE CORPORATION
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/04/2008
Last Update Date: 06/04/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 GROVE ST STE 310
WORCESTER MA
01605-2627
US

IV. Provider business mailing address

100 GROVE ST STE 310
WORCESTER MA
01605-2627
US

V. Phone/Fax

Practice location:
  • Phone: 508-767-1776
  • Fax: 508-767-1726
Mailing address:
  • Phone: 508-767-1776
  • Fax: 508-767-1726

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number7133
License Number StateMA

VII. Legacy identifiers

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

VIII. Authorized Official

Name: MR. TREVOR R RUGGLES
Title or Position: DIRECTOR, ADMINISTRATION & FINANCE
Credential:
Phone: 508-767-1776