MEDICARE: INDEPENDENCE OF PORTAGE COUNTY, 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
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	PENDING	OTHER	OH	PENDING

General Provider Information

NPI Number	:	1932418779
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INDEPENDENCE OF PORTAGE COUNTY, INC.

Provider Business Mailing Address
First Line	:	161 E MAIN ST
Second Line	:
City	:	RAVENNA
State	:	OH
Zip	:	44266-3129
Country	:	US
Telephone Number	:	330-296-2851
Fax Number	:	330-296-8631

Provider Business Practice Location Address
First Line	:	837 CLEVELAND RD
Second Line	:
City	:	RAVENNA
State	:	OH
Zip	:	44266-2023
Country	:	US
Telephone Number	:	330-296-2851
Fax Number	:	330-296-8631

Authorized Official
Title or Position	:	EXECUTIVE DIRECTOR
Name	:	MS. ANNA BARRETT
Credential	:
Telephone Number	:	330-296-2851

Provider Enumeration Date	:	09/28/2010
Last Update Date	:	09/28/2010

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