Provider Demographics
NPI:1679748743
Name:INDEPENDENT FOR LIFE
Entity type:Organization
Organization Name:INDEPENDENT FOR LIFE
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:AGANT OWNER
Authorized Official - Prefix:MS
Authorized Official - First Name:SHARON
Authorized Official - Middle Name:L
Authorized Official - Last Name:MC CANTS
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:513-344-9306
Mailing Address - Street 1:4301 CAPPEL DR
Mailing Address - Street 2:
Mailing Address - City:CINCINNATI
Mailing Address - State:OH
Mailing Address - Zip Code:45205-2023
Mailing Address - Country:US
Mailing Address - Phone:513-344-9306
Mailing Address - Fax:513-251-3522
Practice Address - Street 1:4301 CAPPEL DR
Practice Address - Street 2:
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45205-2023
Practice Address - Country:US
Practice Address - Phone:513-344-9306
Practice Address - Fax:513-251-3522
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2008-04-29
Last Update Date:2008-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2429634302F00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes302F00000XManaged Care OrganizationsExclusive Provider Organization
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2429634OtherMEDICAID PIN ODJFS