1881731271 NPI number — THE INDEPENDENT LIVING CENTER, INC.

Table of content: (NPI 1881731271)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1881731271 NPI number — THE INDEPENDENT LIVING CENTER, INC.

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
THE INDEPENDENT LIVING CENTER, 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:
6
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:
1881731271
Entity Type Code:
Organization
Replacement NPI:
Last Update Date:
10/19/2022
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
2639 E 34TH ST
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
JOPLIN
Provider Business Mailing Address State Name:
MO
Provider Business Mailing Address Postal Code:
64804-4337
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
417-659-8086
Provider Business Mailing Address Fax Number:
417-649-8087

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
2639 E 34TH ST
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
JOPLIN
Provider Business Practice Location Address State Name:
MO
Provider Business Practice Location Address Postal Code:
64804-4337
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
417-659-8086
Provider Business Practice Location Address Fax Number:
417-649-8087
Provider Enumeration Date:
02/01/2007

Additional Information

Authorized Official

Authorized Official Last Name:
NORDSTROM
Authorized Official First Name:
STORMI
Authorized Official Middle Name:
L.
Authorized Official Title or Position:
OFFICE MANAGER
Authorized Official Telephone Number:
417-659-8086

Provider Taxonomy Codes

  • Taxonomy code: 171M00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 253Z00000X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 261QH0100X ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 372500000X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 3747P1801X , registered in the state of MO ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

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

  • Identifier: 266213602 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 266236108 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".
  • Identifier: 286236104 , issued by the state of ( MO ) . This identifiers is of the category "MEDICAID".




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