Provider Demographics
NPI:1144852732
Name:INDEPENDENT LIFESTYLES, INC.
Entity type:Organization
Organization Name:INDEPENDENT LIFESTYLES, INC.
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:ADMINISTRATIVE DIRECTOR
Authorized Official - Prefix:
Authorized Official - First Name:JENNIFER
Authorized Official - Middle Name:A
Authorized Official - Last Name:HERMANSON
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:320-281-2027
Mailing Address - Street 1:215 N BENTON DR
Mailing Address - Street 2:
Mailing Address - City:SAUK RAPIDS
Mailing Address - State:MN
Mailing Address - Zip Code:56379-1530
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:215 N BENTON DR
Practice Address - Street 2:
Practice Address - City:SAUK RAPIDS
Practice Address - State:MN
Practice Address - Zip Code:56379-1530
Practice Address - Country:US
Practice Address - Phone:320-529-9000
Practice Address - Fax:320-529-0747
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-02-11
Last Update Date:2021-12-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes251B00000XAgenciesCase Management
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNA558653000OtherMN DEPT. OF HUMAN SERVICES (DHS) UMPI # FOR PCA CHOICE
MNA768487000OtherMN DEPT. OF HUMAN SERVICES (DHS) UMPI # FOR CASE MGMT.
MNA114035300OtherMN DEPT. OF HUMAN SERVICES (DHS) UMPI # FOR WAIVER SERVICES
MN1068099OtherMN DEPT. OF HUMAN SERVICES (DHS)- 245D LICENSE