1124273479 NPI number — INDEPENDENT LIFESTYLES, INC.

Table of Contents

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1124273479 NPI number — INDEPENDENT LIFESTYLES, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
INDEPENDENT LIFESTYLES, INC.
Provider Last Name:
Provider First Name:
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
Provider Gender Code:

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1124273479
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
11/28/2008
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4405 S DEERWOOD DR
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
NEW BERLIN
Provider Business Mailing Address State Name:
WI
Provider Business Mailing Address Postal Code:
53151-9240
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
262-782-6068
Provider Business Mailing Address Fax Number:
262-827-2642

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4405 S DEERWOOD DR
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
NEW BERLIN
Provider Business Practice Location Address State Name:
WI
Provider Business Practice Location Address Postal Code:
53151-9240
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
262-782-6068
Provider Business Practice Location Address Fax Number:
262-827-2642
Provider Enumeration Date:
11/28/2008

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
HOECHERL
Authorized Official First Name:
DAN
Authorized Official Middle Name:
ALAN
Authorized Official Title or Position:
ADMINISTRATOR/NURSE
Authorized Official Telephone Number:
414-241-5010

Provider Taxonomy Codes

  • Taxonomy code: 320700000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 320800000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)