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General NPI Number Information
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NPI Number | 1831746643
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Entity Type | Organization
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Legal Business Name | INDEPENDENT LIFE ANNEX
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Dates
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Enumeration Date | 08/26/2019
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Last Update Date | 08/26/2019
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Provider Practice Location Address
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Address Line | 6610 GREENSPRING DR
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City | ARLINGTON
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State | TX
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Zip | 76016-5134
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Country | US
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Telephone | 469-712-4452
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Fax |
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Provider Business Mailing Address
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Address Line | PO BOX 155046
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City | IRVING
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State | TX
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Zip | 75015-5046
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Country | US
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Telephone | 469-712-4452
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | DEDRIC ASHLEY
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Credential |
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Telephone | 469-712-4452
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 372600000X
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Taxonomy Name | Adult Companion
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 3104A0625X
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Taxonomy Name | Assisted Living Facility (Mental Illness)
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License Number |
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License Number State |
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