Provider Demographics
NPI:1689673295
Name:INDEPENDENCE CARE COMMUNITY INC
Entity Type:Organization
Organization Name:INDEPENDENCE CARE COMMUNITY INC
Other - Org Name:INDEPENDENCE HOUSE
Other - Org Type:Doing Business As
Authorized Official - Title/Position:ADMINISTRATOR
Authorized Official - Prefix:MRS
Authorized Official - First Name:BRIDGETT
Authorized Official - Middle Name:M
Authorized Official - Last Name:GAMBY-MUNDY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:419-435-8505
Mailing Address - Street 1:1000 INDEPENDENCE RD.
Mailing Address - Street 2:
Mailing Address - City:FOSTORIA
Mailing Address - State:OH
Mailing Address - Zip Code:44830
Mailing Address - Country:US
Mailing Address - Phone:419-435-8505
Mailing Address - Fax:419-435-0829
Practice Address - Street 1:1000 INDEPENDENCE RD
Practice Address - Street 2:
Practice Address - City:FOSTORIA
Practice Address - State:OH
Practice Address - Zip Code:44830
Practice Address - Country:US
Practice Address - Phone:419-435-8505
Practice Address - Fax:419-435-0829
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:INDEPENDENCE CARE COMMUNITY INC DBA INDEPENDENCE HOUSE
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2005-07-15
Last Update Date:2008-01-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH1951314000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes314000000XNursing & Custodial Care FacilitiesSkilled Nursing Facility
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0960189Medicaid
365860Medicare PIN