Healthcare Provider Details

I. General information

NPI: 1124273479
Provider Name (Legal Business Name): INDEPENDENT LIFESTYLES, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/28/2008
Last Update Date: 11/28/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4405 S DEERWOOD DR
NEW BERLIN WI
53151-9240
US

IV. Provider business mailing address

4405 S DEERWOOD DR
NEW BERLIN WI
53151-9240
US

V. Phone/Fax

Practice location:
  • Phone: 262-782-6068
  • Fax: 262-827-2642
Mailing address:
  • Phone: 262-782-6068
  • Fax: 262-827-2642

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code320700000X
TaxonomyPhysical Disabilities Residential Treatment Facility
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code320800000X
TaxonomyMental Illness Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: MR. DAN ALAN HOECHERL
Title or Position: ADMINISTRATOR/NURSE
Credential: RN
Phone: 414-241-5010