MEDICARE: INTEGRATED LIFE CHOICES (ILC)

Medicare Provider Information

Scope of Practice

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

#	Taxonomy Code	Taxonomy
1	320900000X	Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
2	343900000X	Non-emergency Medical Transport (VAN)
3	385HR2060X	Child Intellectual and/or Developmental Disabilities Respite Care
4	251C00000X	Developmentally Disabled Services Day Training 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	:	1962086090
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	INTEGRATED LIFE CHOICES (ILC)

Provider Business Mailing Address
First Line	:	PO BOX 80728
Second Line	:
City	:	LINCOLN
State	:	NE
Zip	:	68501-0728
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	3015 S ACADEMY BLVD
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80916-3201
Country	:	US
Telephone Number	:	720-830-8686
Fax Number	:

Authorized Official
Title or Position	:	QUALITY IMPROVEMENT COORDINATOR
Name	:	MR. RUSS HERNANDEZ
Credential	:
Telephone Number	:	303-484-8990

Provider Enumeration Date	:	05/05/2021
Last Update Date	:	05/05/2021

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Directions to “INTEGRATED LIFE CHOICES (ILC) ” Practice Location

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