Provider Demographics
NPI:1568890820
Name:IND HALL LLC
Entity Type:Organization
Organization Name:IND HALL LLC
Other - Org Name:INDEPENDENCE HALL
Other - Org Type:Doing Business As
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:JON
Authorized Official - Middle Name:R
Authorized Official - Last Name:EVANS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:817-475-0409
Mailing Address - Street 1:1210 JACKSON ST
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:TX
Mailing Address - Zip Code:76230-3034
Mailing Address - Country:US
Mailing Address - Phone:940-872-9718
Mailing Address - Fax:940-872-8590
Practice Address - Street 1:1210 JACKSON ST
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:TX
Practice Address - Zip Code:76230-3034
Practice Address - Country:US
Practice Address - Phone:940-872-9718
Practice Address - Fax:940-872-8590
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2013-10-24
Last Update Date:2013-10-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX133835310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility