Provider Demographics
NPI:1013570274
Name:INDEPENDENCE AT HOME HOMECARE, LLC
Entity Type:Organization
Organization Name:INDEPENDENCE AT HOME HOMECARE, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JOHN
Authorized Official - Middle Name:E
Authorized Official - Last Name:SAFONOV
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:479-208-3757
Mailing Address - Street 1:PO BOX 6292
Mailing Address - Street 2:
Mailing Address - City:VAN BUREN
Mailing Address - State:AR
Mailing Address - Zip Code:72956-0241
Mailing Address - Country:US
Mailing Address - Phone:479-208-3757
Mailing Address - Fax:479-208-4098
Practice Address - Street 1:2711 OAK LANE STE 2
Practice Address - Street 2:
Practice Address - City:VAN BUREN
Practice Address - State:AR
Practice Address - Zip Code:72956-8806
Practice Address - Country:US
Practice Address - Phone:479-316-0273
Practice Address - Fax:479-208-4098
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-04-15
Last Update Date:2022-10-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care
No251B00000XAgenciesCase Management
No385HR2065XRespite Care FacilityRespite CareRespite Care, Physical Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR232603732Medicaid