Provider Demographics
NPI:1538101951
Name:INDEPENDENCE FAMILY CARE CENTER, PC
Entity type:Organization
Organization Name:INDEPENDENCE FAMILY CARE CENTER, PC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:NANCE
Authorized Official - Middle Name:ANN
Authorized Official - Last Name:LOVELACE
Authorized Official - Suffix:
Authorized Official - Credentials:DO
Authorized Official - Phone:276-773-2111
Mailing Address - Street 1:217 S INDEPENDENCE AVE
Mailing Address - Street 2:
Mailing Address - City:INDEPENDENCE
Mailing Address - State:VA
Mailing Address - Zip Code:24348-2802
Mailing Address - Country:US
Mailing Address - Phone:276-773-2111
Mailing Address - Fax:273-773-2942
Practice Address - Street 1:217 S INDEPENDENCE AVE
Practice Address - Street 2:
Practice Address - City:INDEPENDENCE
Practice Address - State:VA
Practice Address - Zip Code:24348-2802
Practice Address - Country:US
Practice Address - Phone:276-773-2111
Practice Address - Fax:273-773-2942
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-06-11
Last Update Date:2011-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily MedicineGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010084326Medicaid
VA010134129Medicaid
VAS66686OtherREYNOLDS
VA010094640Medicaid
VA143862OtherBCBS
VAF86071Medicare UPIN
VA498904Medicare ID - Type UnspecifiedMEDICARE VERTIUS
VAS66686OtherREYNOLDS
VAC09139Medicare ID - Type UnspecifiedMEDICARE TRAILBLAZER
VA010134129Medicaid