Basic Information
| Provider Information | |||||||||
| NPI: | 1144567017 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | INDEPENDENCE LIFESTYLES INC | ||||||||
| LastName: | |||||||||
| FirstName: | |||||||||
| MiddleName: | |||||||||
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| Credential: | |||||||||
| OtherOrganizationName: | VISITING ANGELS | ||||||||
| OtherOrganizationType: | 3 | ||||||||
| OtherLastName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 1701 N GREEN VALLEY PKWY | ||||||||
| Address2: | SUITE 9A | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890745885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024071100 | ||||||||
| FaxNumber: | 7026144783 | ||||||||
| Practice Location | |||||||||
| Address1: | 1701 N GREEN VALLEY PKWY | ||||||||
| Address2: | SUITE 9A | ||||||||
| City: | HENDERSON | ||||||||
| State: | NV | ||||||||
| PostalCode: | 890745885 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7024071100 | ||||||||
| FaxNumber: | 7026144783 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/11/2013 | ||||||||
| LastUpdateDate: | 01/11/2013 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | DIASIO | ||||||||
| AuthorizedOfficialFirstName: | JACQUELYN | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OWNER | ||||||||
| AuthorizedOfficialTelephone: | 7024071100 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
| AuthorizedOfficialNameSuffix: | |||||||||
| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 253Z00000X | 5291PCS-3 | NV | Y | Agencies | In Home Supportive Care |
No ID Information.