Provider Demographics
NPI:1194416446
Name:INDEPENDENT SUPPORT CARE SERVICE LLC
Entity type:Organization
Organization Name:INDEPENDENT SUPPORT CARE SERVICE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:NATWONA
Authorized Official - Middle Name:
Authorized Official - Last Name:FULLER
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:561-856-2081
Mailing Address - Street 1:PO BOX 16604
Mailing Address - Street 2:
Mailing Address - City:WEST PALM BEACH
Mailing Address - State:FL
Mailing Address - Zip Code:33416-6604
Mailing Address - Country:US
Mailing Address - Phone:561-856-2081
Mailing Address - Fax:
Practice Address - Street 1:2188 S HAVERHILL RD
Practice Address - Street 2:
Practice Address - City:WEST PALM BEACH
Practice Address - State:FL
Practice Address - Zip Code:33415-7352
Practice Address - Country:US
Practice Address - Phone:561-856-2081
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2023-05-17
Last Update Date:2023-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251C00000XAgenciesDay Training, Developmentally Disabled Services
No251E00000XAgenciesHome Health