=====================================================
General NPI Number Information
=====================================================
NPI Number | 1700771037
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | ENDEPENDENCE, LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 06/09/2025
-----------------------------------------------------
Last Update Date | 06/09/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 4410 CLAIBORNE SQ E STE 334
-----------------------------------------------------
City | HAMPTON
-----------------------------------------------------
State | VA
-----------------------------------------------------
Zip | 23666-2074
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-713-1296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 2822 PICKETT RD APT 154
-----------------------------------------------------
City | DURHAM
-----------------------------------------------------
State | NC
-----------------------------------------------------
Zip | 27705-9307
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 757-713-1296
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | ANTHONY OTIS
-----------------------------------------------------
Credential | MSW
-----------------------------------------------------
Telephone | 757-713-1296
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------