Healthcare Provider Details

I. General information

NPI: 1619963972
Provider Name (Legal Business Name): INDEPENDENCE HEALTH SYSTEM, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 09/22/2005
Last Update Date: 11/19/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

800 S KINGSHIGHWAY ST
PERRYVILLE MO
63775-2106
US

IV. Provider business mailing address

800 S KINGSHIGHWAY ST
PERRYVILLE MO
63775-2106
US

V. Phone/Fax

Practice location:
  • Phone: 573-547-6546
  • Fax: 573-547-2823
Mailing address:
  • Phone: 573-547-6546
  • Fax: 573-547-2823

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code310400000X
TaxonomyAssisted Living Facility
License Number031348
License Number StateMO
# 2
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number031654
License Number StateMO

VIII. Authorized Official

Name: MRS. BONNIE SCHNURBUSCH
Title or Position: ADMINISTRATOR
Credential:
Phone: 573-547-6546