Healthcare Provider Details

I. General information

NPI: 1114099165
Provider Name (Legal Business Name): INDEPENDANCE MODIFICATIONS INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/14/2006
Last Update Date: 08/22/2020
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

24819 LEVER ST NE
ISANTI MN
55040-4648
US

IV. Provider business mailing address

24819 LEVER ST NE
ISANTI MN
55040-4648
US

V. Phone/Fax

Practice location:
  • Phone: 651-755-4459
  • Fax: 763-444-6851
Mailing address:
  • Phone: 651-755-4459
  • Fax: 763-444-6851

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171WH0202X
TaxonomyHome Modifications Contractor
License Number20529716
License Number StateMN

VIII. Authorized Official

Name: MR. BRENT RYAN KELSEY
Title or Position: PRESIDENT
Credential:
Phone: 651-755-4459