Provider Demographics
NPI:1023208972
Name:INDEPENDENT LIFE LLC
Entity Type:Organization
Organization Name:INDEPENDENT LIFE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:AUTHORIZED.REPRESENTATIVE
Authorized Official - Prefix:MRS
Authorized Official - First Name:PRINCE
Authorized Official - Middle Name:E
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:OT
Authorized Official - Phone:561-385-0868
Mailing Address - Street 1:4047 OCKEECHOBEE BLVD.
Mailing Address - Street 2:STE 123
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33409-3236
Mailing Address - Country:US
Mailing Address - Phone:561-385-0868
Mailing Address - Fax:
Practice Address - Street 1:4047 OCKEECHOBEE BLVD.
Practice Address - Street 2:STE 123
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33409-3236
Practice Address - Country:US
Practice Address - Phone:561-385-0868
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-07-26
Last Update Date:2010-01-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL261QR0401X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes261QR0401XAmbulatory Health Care FacilitiesClinic/CenterRehabilitation, Comprehensive Outpatient Rehabilitation Facility (CORF)