Healthcare Provider Details

I. General information

NPI: 1477674984
Provider Name (Legal Business Name): INDEPENDENCE HOUSE, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 04/02/2007
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5561 FRANKLIN RD
BLOOMFIELD HILLS MI
48301-1158
US

IV. Provider business mailing address

26900 FRANKLIN RD
SOUTHFIELD MI
48033-5312
US

V. Phone/Fax

Practice location:
  • Phone: 248-538-9578
  • Fax:
Mailing address:
  • Phone: 248-350-8070
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number StateMI

VIII. Authorized Official

Name: MR. GARY ERNEST ROMANELLI
Title or Position: COO & CFO
Credential:
Phone: 248-350-8070