Healthcare Provider Details

I. General information

NPI: 1992302384
Provider Name (Legal Business Name): INDEPENDENT COMMUNITY SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/08/2020
Last Update Date: 10/08/2020
Certification Date: 10/08/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

675 DEIS DR # 201
FAIRFIELD OH
45014-8136
US

IV. Provider business mailing address

675 DEIS DR # 201
FAIRFIELD OH
45014-8136
US

V. Phone/Fax

Practice location:
  • Phone: 513-817-4888
  • Fax:
Mailing address:
  • Phone: 513-817-4888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251C00000X
TaxonomyDevelopmentally Disabled Services Day Training Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MISS KARISSA JANAY MARSHALL
Title or Position: CEO
Credential:
Phone: 423-316-0557