=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790997955
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | INDEPENDENT GROWTH
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 05/03/2007
-----------------------------------------------------
Last Update Date | 07/21/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 2173 OVERLAND AVE BOX 756
-----------------------------------------------------
City | BURLEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83318-2927
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-678-9165
-----------------------------------------------------
Fax | 208-679-5985
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 756
-----------------------------------------------------
City | BURLEY
-----------------------------------------------------
State | ID
-----------------------------------------------------
Zip | 83318-0756
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 208-678-9165
-----------------------------------------------------
Fax | 208-679-5985
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | LYNDA BRENNEN
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone | 208-678-9165
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 251B00000X
-----------------------------------------------------
Taxonomy Name | Case Management Agency
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State | ID
-----------------------------------------------------