Healthcare Provider Details

I. General information

NPI: 1881731271
Provider Name (Legal Business Name): THE INDEPENDENT LIVING CENTER, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/01/2007
Last Update Date: 10/19/2022
Certification Date: 10/19/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2639 E 34TH ST
JOPLIN MO
64804-4337
US

IV. Provider business mailing address

2639 E 34TH ST
JOPLIN MO
64804-4337
US

V. Phone/Fax

Practice location:
  • Phone: 417-659-8086
  • Fax: 417-649-8087
Mailing address:
  • Phone: 417-659-8086
  • Fax: 417-649-8087

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code261QH0100X
TaxonomyHealth Service Clinic/Center
License Number
License Number StateNULL
# 2
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number StateMO
# 3
Primary TaxonomyY
Taxonomy Code3747P1801X
TaxonomyPersonal Care Attendant
License Number
License Number StateMO
# 4
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number StateNULL
# 5
Primary TaxonomyN
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number StateNULL

VIII. Authorized Official

Name: MRS. STORMI L. NORDSTROM
Title or Position: OFFICE MANAGER
Credential:
Phone: 417-659-8086