Provider Demographics
NPI:1669861217
Name:INDEPENDENCE LIVING SOLUTIONS INC
Entity Type:Organization
Organization Name:INDEPENDENCE LIVING SOLUTIONS INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:MR
Authorized Official - First Name:TAMBA
Authorized Official - Middle Name:
Authorized Official - Last Name:NGAUJA
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:904-374-1722
Mailing Address - Street 1:2822 SPOONBILL TRL
Mailing Address - Street 2:
Mailing Address - City:ORANGE PARK
Mailing Address - State:FL
Mailing Address - Zip Code:32073-1654
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2822 SPOONBILL TRL
Practice Address - Street 2:
Practice Address - City:ORANGE PARK
Practice Address - State:FL
Practice Address - Zip Code:32073-1654
Practice Address - Country:US
Practice Address - Phone:904-374-1722
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2015-01-21
Last Update Date:2015-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251E00000XAgenciesHome Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL012283500Medicaid
FL004282900Medicaid