Provider Demographics
NPI:1336143395
Name:INDEPENDENCEFIRST
Entity Type:Organization
Organization Name:INDEPENDENCEFIRST
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:COO
Authorized Official - Prefix:MRS
Authorized Official - First Name:DEB
Authorized Official - Middle Name:
Authorized Official - Last Name:LANGHAM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:414-226-8371
Mailing Address - Street 1:540 S 1ST ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53204-1605
Mailing Address - Country:US
Mailing Address - Phone:414-291-7520
Mailing Address - Fax:414-291-7525
Practice Address - Street 1:540 S 1ST ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53204-1605
Practice Address - Country:US
Practice Address - Phone:414-291-7520
Practice Address - Fax:414-291-7525
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2005-06-08
Last Update Date:2019-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI43104200251E00000X
251E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI43104200Medicaid