Provider Demographics
NPI:1255829610
Name:INDEPENDENCE PLACE, INC
Entity Type:Organization
Organization Name:INDEPENDENCE PLACE, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:WILLIS
Authorized Official - Middle Name:
Authorized Official - Last Name:DEITZ
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:270-871-5617
Mailing Address - Street 1:2358 NICHOLASVILLE RD STE 180
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:KY
Mailing Address - Zip Code:40503-3049
Mailing Address - Country:US
Mailing Address - Phone:859-266-2807
Mailing Address - Fax:859-335-0627
Practice Address - Street 1:2358 NICHOLASVILLE RD STE 180
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40503-3049
Practice Address - Country:US
Practice Address - Phone:859-266-2807
Practice Address - Fax:859-335-0627
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2018-05-01
Last Update Date:2018-05-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management