MEDICARE: INDEPENDENT MOBILITY LLC

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	332BC3200X	Customized Equipment (DME)
2	332B00000X	Durable Medical Equipment & Medical Supplies

General Provider Information

NPI Number	:	1710244363
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENT MOBILITY LLC

Provider Business Mailing Address
First Line	:	18994 HIGHWAY 19
Second Line	:
City	:	NEW LONDON
State	:	MO
Zip	:	63459-4808
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	18994 HIGHWAY 19
Second Line	:
City	:	NEW LONDON
State	:	MO
Zip	:	63459-4808
Country	:	US
Telephone Number	:	217-653-5031
Fax Number	:

Authorized Official
Title or Position	:	PARTNER
Name	:	PHILLIP BRENT COWDEN
Credential	:
Telephone Number	:	217-653-5031

Provider Enumeration Date	:	04/20/2012
Last Update Date	:	04/20/2012

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