Healthcare Provider Details

I. General information

NPI: 1760735260
Provider Name (Legal Business Name): INDEPENDENT COMMUNITY LIVING
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/21/2012
Last Update Date: 10/21/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5630 N EASY ST
SANFORD MI
48657-9310
US

IV. Provider business mailing address

5630 N EASY ST
SANFORD MI
48657-9310
US

V. Phone/Fax

Practice location:
  • Phone: 989-615-1915
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251E00000X
TaxonomyHome Health Agency
License Number
License Number State

VIII. Authorized Official

Name: MS. SARAH KEPLER
Title or Position: CHEIF EXECUTIVE OFFICER
Credential:
Phone: 989-615-1915