=====================================================
General NPI Number Information
=====================================================
NPI Number | 1669522967
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDEPENDENT FOR LIFE, INC.
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/11/2007
-----------------------------------------------------
Last Update Date | 12/15/2009
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4015 PROGRESS BLVD
-----------------------------------------------------
City | PERU
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61354-1123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-494-1948
-----------------------------------------------------
Fax | 815-780-1688
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 4015 PROGRESS BLVD
-----------------------------------------------------
City | PERU
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 61354-1123
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 866-494-1948
-----------------------------------------------------
Fax | 815-780-1688
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | MANAGER
-----------------------------------------------------
Name | MR. ROBERT NUDD JR.
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 866-494-1948
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 332B00000X
-----------------------------------------------------
Taxonomy Name | Durable Medical Equipment & Medical Supplies
-----------------------------------------------------
License Number | 203.000841
-----------------------------------------------------
License Number State | IL
-----------------------------------------------------