MEDICARE: INDEPENDENCE CENTER

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	320800000X	Mental Illness Community Based Residential Treatment Facility	030777	MO

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1174669006
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENCE CENTER

Provider Business Mailing Address
First Line	:	8675 OLIVE BLVD
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63132-2503
Country	:	US
Telephone Number	:	314-373-5187
Fax Number	:	314-367-5626

Provider Business Practice Location Address
First Line	:	2443 PROUHET AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63114-1946
Country	:	US
Telephone Number	:	314-890-7100
Fax Number	:	314-890-7133

Authorized Official
Title or Position	:	EXECTUVE DIRECTOR
Name	:	MRS. PATRICIA HOLMES
Credential	:
Telephone Number	:	314-880-5415

Provider Enumeration Date	:	01/29/2007
Last Update Date	:	06/27/2022

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Directions to “INDEPENDENCE CENTER ” Practice Location

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