Provider Demographics
NPI:1861004491
Name:INDEPENDENT LIVING HOME CARE L. L.C.
Entity Type:Organization
Organization Name:INDEPENDENT LIVING HOME CARE L. L.C.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER/VP
Authorized Official - Prefix:
Authorized Official - First Name:ALICIA
Authorized Official - Middle Name:
Authorized Official - Last Name:GREEN
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:267-252-1119
Mailing Address - Street 1:6115 MANTLE RD
Mailing Address - Street 2:
Mailing Address - City:BURKE
Mailing Address - State:VA
Mailing Address - Zip Code:22015-3807
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:6115 MANTLE RD
Practice Address - Street 2:
Practice Address - City:BURKE
Practice Address - State:VA
Practice Address - Zip Code:22015-3807
Practice Address - Country:US
Practice Address - Phone:267-252-1119
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-08-17
Last Update Date:2020-08-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes253Z00000XAgenciesIn Home Supportive Care