Healthcare Provider Details

I. General information

NPI: 1831746643
Provider Name (Legal Business Name): INDEPENDENT LIFE ANNEX
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 08/26/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6610 GREENSPRING DR
ARLINGTON TX
76016-5134
US

IV. Provider business mailing address

PO BOX 155046
IRVING TX
75015-5046
US

V. Phone/Fax

Practice location:
  • Phone: 469-712-4452
  • Fax:
Mailing address:
  • Phone: 469-712-4452
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code3104A0625X
TaxonomyAssisted Living Facility (Mental Illness)
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name: DEDRIC ASHLEY
Title or Position: OWNER
Credential:
Phone: 469-712-4452