Healthcare Provider Details

I. General information

NPI: 1689673295
Provider Name (Legal Business Name): INDEPENDENCE CARE COMMUNITY INC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 07/15/2005
Last Update Date: 01/29/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1000 INDEPENDENCE RD
FOSTORIA OH
44830
US

IV. Provider business mailing address

1000 INDEPENDENCE RD.
FOSTORIA OH
44830
US

V. Phone/Fax

Practice location:
  • Phone: 419-435-8505
  • Fax: 419-435-0829
Mailing address:
  • Phone: 419-435-8505
  • Fax: 419-435-0829

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code314000000X
TaxonomySkilled Nursing Facility
License Number1951
License Number StateOH

VIII. Authorized Official

Name: MRS. BRIDGETT M GAMBY-MUNDY
Title or Position: ADMINISTRATOR
Credential:
Phone: 419-435-8505