Provider Demographics
NPI:1831746643
Name:INDEPENDENT LIFE ANNEX
Entity type:Organization
Organization Name:INDEPENDENT LIFE ANNEX
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:DEDRIC
Authorized Official - Middle Name:
Authorized Official - Last Name:ASHLEY
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:469-712-4452
Mailing Address - Street 1:PO BOX 155046
Mailing Address - Street 2:
Mailing Address - City:IRVING
Mailing Address - State:TX
Mailing Address - Zip Code:75015-5046
Mailing Address - Country:US
Mailing Address - Phone:469-712-4452
Mailing Address - Fax:
Practice Address - Street 1:6610 GREENSPRING DR
Practice Address - Street 2:
Practice Address - City:ARLINGTON
Practice Address - State:TX
Practice Address - Zip Code:76016-5134
Practice Address - Country:US
Practice Address - Phone:469-712-4452
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2019-08-26
Last Update Date:2019-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3104A0625XNursing & Custodial Care FacilitiesAssisted Living FacilityAssisted Living, Mental IllnessGroup - Single Specialty
No372600000XNursing Service Related ProvidersAdult CompanionGroup - Single Specialty