Provider Demographics
NPI:1245483262
Name:INDEPENDENT LIVING SERVICES
Entity type:Organization
Organization Name:INDEPENDENT LIVING SERVICES
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JACKIE
Authorized Official - Middle Name:
Authorized Official - Last Name:FLISS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:501-327-5234
Mailing Address - Street 1:1105 DEER ST STE 9
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:AR
Mailing Address - Zip Code:72032-5450
Mailing Address - Country:US
Mailing Address - Phone:501-327-5883
Mailing Address - Fax:
Practice Address - Street 1:1105 DEER ST STE 9
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:AR
Practice Address - Zip Code:72032-5450
Practice Address - Country:US
Practice Address - Phone:501-327-5883
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-11-04
Last Update Date:2008-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AROTR-1868251C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR152002721Medicaid