Provider Demographics
NPI:1881731271
Name:THE INDEPENDENT LIVING CENTER, INC.
Entity type:Organization
Organization Name:THE INDEPENDENT LIVING CENTER, INC.
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OFFICE MANAGER
Authorized Official - Prefix:MRS
Authorized Official - First Name:STORMI
Authorized Official - Middle Name:L
Authorized Official - Last Name:NORDSTROM
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:417-659-8086
Mailing Address - Street 1:2639 E 34TH ST
Mailing Address - Street 2:
Mailing Address - City:JOPLIN
Mailing Address - State:MO
Mailing Address - Zip Code:64804-4337
Mailing Address - Country:US
Mailing Address - Phone:417-659-8086
Mailing Address - Fax:417-649-8087
Practice Address - Street 1:2639 E 34TH ST
Practice Address - Street 2:
Practice Address - City:JOPLIN
Practice Address - State:MO
Practice Address - Zip Code:64804-4337
Practice Address - Country:US
Practice Address - Phone:417-659-8086
Practice Address - Fax:417-649-8087
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-01
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X, 253Z00000X, 261QH0100X
MO372500000X, 3747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care AttendantGroup - Multi-Specialty
No171M00000XOther Service ProvidersCase Manager/Care CoordinatorGroup - Multi-Specialty
No253Z00000XAgenciesIn Home Supportive CareGroup - Multi-Specialty
No261QH0100XAmbulatory Health Care FacilitiesClinic/CenterHealth ServiceGroup - Multi-Specialty
No372500000XNursing Service Related ProvidersChore ProviderGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO266213602Medicaid
MO266236108Medicaid
MO286236104Medicaid