Provider Demographics
NPI:1669522967
Name:INDEPENDENT FOR LIFE, INC.
Entity type:Organization
Organization Name:INDEPENDENT FOR LIFE, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:MANAGER
Authorized Official - Prefix:MR
Authorized Official - First Name:ROBERT
Authorized Official - Middle Name:
Authorized Official - Last Name:NUDD
Authorized Official - Suffix:JR
Authorized Official - Credentials:
Authorized Official - Phone:866-494-1948
Mailing Address - Street 1:4015 PROGRESS BLVD
Mailing Address - Street 2:
Mailing Address - City:PERU
Mailing Address - State:IL
Mailing Address - Zip Code:61354-1123
Mailing Address - Country:US
Mailing Address - Phone:866-494-1948
Mailing Address - Fax:815-780-1688
Practice Address - Street 1:4015 PROGRESS BLVD
Practice Address - Street 2:
Practice Address - City:PERU
Practice Address - State:IL
Practice Address - Zip Code:61354-1123
Practice Address - Country:US
Practice Address - Phone:866-494-1948
Practice Address - Fax:815-780-1688
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-01-11
Last Update Date:2009-12-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL203.000841332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL=========-61354-01Medicaid
IL=========-61354-01Medicaid