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General NPI Number Information
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NPI Number | 1114355476
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Entity Type | Organization
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Legal Business Name | INDEPENDENT GUARDIAN LLC
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Dates
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Enumeration Date | 10/24/2013
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Last Update Date | 10/24/2013
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Provider Practice Location Address
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Address Line | 550 S ESTELLE ST
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City | WICHITA
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State | KS
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Zip | 67211-2909
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Country | US
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Telephone | 316-880-1742
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Fax |
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Provider Business Mailing Address
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Address Line | 550 S ESTELLE ST
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City | WICHITA
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State | KS
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Zip | 67211-2909
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Country | US
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Telephone | 316-880-1742
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | AARON DECKINGER
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Credential |
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Telephone | 316-880-1742
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 385HR2060X
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Taxonomy Name | Child Intellectual and/or Developmental Disabilities Respite Care
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License Number | 200566240A
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License Number State | KS
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