Provider Demographics
NPI:1285902320
Name:INDEPENDENT HOMES, INC
Entity type:Organization
Organization Name:INDEPENDENT HOMES, INC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:EXECUTIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:PASCAL
Authorized Official - Middle Name:
Authorized Official - Last Name:THEBAUD
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:804-721-1720
Mailing Address - Street 1:PO BOX 3163
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-3163
Mailing Address - Country:US
Mailing Address - Phone:804-721-1720
Mailing Address - Fax:804-214-2177
Practice Address - Street 1:1816 ARCH ST
Practice Address - Street 2:
Practice Address - City:PETERSBURG
Practice Address - State:VA
Practice Address - Zip Code:23805-1618
Practice Address - Country:US
Practice Address - Phone:804-721-1720
Practice Address - Fax:804-214-2177
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2011-12-04
Last Update Date:2011-12-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA139901001320600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320600000XResidential Treatment FacilitiesResidential Treatment Facility, Intellectual and/or Developmental Disabilities