Provider Demographics
NPI:1689382954
Name:INDEPENDENCE HALL OPERATOR, LLC
Entity Type:Organization
Organization Name:INDEPENDENCE HALL OPERATOR, LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGING PARTNER
Authorized Official - Prefix:MR
Authorized Official - First Name:THOMAS
Authorized Official - Middle Name:MICHAEL
Authorized Official - Last Name:RABOLD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:954-496-0387
Mailing Address - Street 1:215 N NEW RIVER DR E APT 1600
Mailing Address - Street 2:
Mailing Address - City:FORT LAUDERDALE
Mailing Address - State:FL
Mailing Address - Zip Code:33301-1091
Mailing Address - Country:US
Mailing Address - Phone:954-496-0387
Mailing Address - Fax:
Practice Address - Street 1:1639 NE 26TH ST
Practice Address - Street 2:
Practice Address - City:WILTON MANORS
Practice Address - State:FL
Practice Address - Zip Code:33305-1410
Practice Address - Country:US
Practice Address - Phone:954-563-6232
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2022-11-07
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility