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	251S00000X	Community/Behavioral Health Agency

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	:	1558494286
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	:	4245 FOREST PARK AVE
Second Line	:
City	:	SAINT LOUIS
State	:	MO
Zip	:	63108-2810
Country	:	US
Telephone Number	:	314-880-5415
Fax Number	:

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

Provider Enumeration Date	:	03/13/2007
Last Update Date	:	06/27/2022

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Practice Location Address:

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1871521575 — WASHINGTON UNIVERSITY
Practice Location Address:

4205 FOREST PARK AVE
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63108-2810

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1184642662 — MS. LISA A KOESTER-WIEDEMANN ANP
Practice Location Address:

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1801094594 — SUSAN M BENDER RN
Practice Location Address:

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Directions to “INDEPENDENCE CENTER ” Practice Location

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