Provider Demographics
NPI:1588610273
Name:INDEPENDENCE, INC.
Entity Type:Organization
Organization Name:INDEPENDENCE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:DIANE
Authorized Official - Middle Name:ELAINE
Authorized Official - Last Name:MOORE
Authorized Official - Suffix:
Authorized Official - Credentials:LSW
Authorized Official - Phone:208-524-0881
Mailing Address - Street 1:1230 N SKYLINE, STE A
Mailing Address - Street 2:1230 N SKYLINE, STE A
Mailing Address - City:IDAHO FALLS
Mailing Address - State:ID
Mailing Address - Zip Code:83405
Mailing Address - Country:US
Mailing Address - Phone:208-524-0881
Mailing Address - Fax:208-524-0886
Practice Address - Street 1:1230 N SKYLINE, STE A
Practice Address - Street 2:1230 N SKYLINE, STE A
Practice Address - City:IDAHO FALLS
Practice Address - State:ID
Practice Address - Zip Code:83405
Practice Address - Country:US
Practice Address - Phone:208-524-0881
Practice Address - Fax:208-524-0886
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-05-25
Last Update Date:2020-08-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ID251B00000X, 251B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management