Provider Demographics
NPI:1639336340
Name:INDEPENDENT LIVING SERVICES, INC. (ILS)
Entity Type:Organization
Organization Name:INDEPENDENT LIVING SERVICES, INC. (ILS)
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATOR/OWNER
Authorized Official - Prefix:MR
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:A
Authorized Official - Last Name:KELLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:618-833-5070
Mailing Address - Street 1:158 E VIENNA ST
Mailing Address - Street 2:
Mailing Address - City:ANNA
Mailing Address - State:IL
Mailing Address - Zip Code:62906-1840
Mailing Address - Country:US
Mailing Address - Phone:618-833-5070
Mailing Address - Fax:618-833-4993
Practice Address - Street 1:158 E VIENNA ST
Practice Address - Street 2:
Practice Address - City:ANNA
Practice Address - State:IL
Practice Address - Zip Code:62906-1840
Practice Address - Country:US
Practice Address - Phone:618-833-5070
Practice Address - Fax:618-833-4993
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-05-20
Last Update Date:2008-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL94S218320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========Medicaid