Provider Demographics
NPI:1730247669
Name:INDEPENDENT MOBILITY
Entity type:Organization
Organization Name:INDEPENDENT MOBILITY
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:JAMES
Authorized Official - Middle Name:
Authorized Official - Last Name:COSTANZO
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:570-825-1277
Mailing Address - Street 1:147 1/2 AMBER LN
Mailing Address - Street 2:
Mailing Address - City:WILKES BARRE
Mailing Address - State:PA
Mailing Address - Zip Code:18702-6545
Mailing Address - Country:US
Mailing Address - Phone:570-825-1277
Mailing Address - Fax:570-825-1278
Practice Address - Street 1:147 1/2 AMBER LN
Practice Address - Street 2:
Practice Address - City:WILKES BARRE
Practice Address - State:PA
Practice Address - Zip Code:18702-6545
Practice Address - Country:US
Practice Address - Phone:570-825-1277
Practice Address - Fax:570-825-1278
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2006-12-04
Last Update Date:2008-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA6000005585332B00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
PA6000005585Medicaid
PA6000005585Medicaid