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NPI Code Detail

MEDICARE: INDEPENDENCE PLACE, INC.

MEDICARE: INDEPENDENCE PLACE, INC.
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
1313M00000XNursing Facility/Intermediate Care Facility0037994IL

General Provider Information

NPI Number : 1871717678
Entity Type Code : Organization
Provider Name (Legal Business Name) : INDEPENDENCE PLACE, INC.
Provider Business Mailing Address
First Line : 15755 NIXON RD
Second Line :
City : NASHVILLE
State : IL
Zip : 62263-4815
Country : US
Telephone Number : 618-327-9846
Fax Number : 618-327-9845
Provider Business Practice Location Address
First Line : 1705 S PARK AVE
Second Line :
City : HERRIN
State : IL
Zip : 62948-4166
Country : US
Telephone Number : 618-942-7964
Fax Number : 618-942-6191
Authorized Official
Title or Position : VICE PRESIDENT
Name : MS. JANE M DODSON
Credential :
Telephone Number : 618-327-9846
Provider Enumeration Date : 04/12/2007
Last Update Date : 08/22/2020

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Directions to “INDEPENDENCE PLACE, INC. ” Practice Location

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