| Organization Name: | INDEPENDANCE MODIFICATIONS INC |
| NPI Number: | 1114099165 |
| Entity Type Code: | Organizational (2) |
| Authorized Official Name: | BRENT RYAN KELSEY (PRESIDENT) |
| Mailing Address: | 24819 Lever St Ne Isanti |
| State: | MN US |
| Postal Code: | 550404648 |
| Phone Number: | 6517554459 |
| Fax Number: | 7634446851 |
| NPI Enumeration Date: | 11/14/2006 |
| NPI Last Update Date: | 07/08/2007 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 171WH0202X |
| License Number: | 20529716 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | MN |
| Taxonomy Type: | Other Service Providers |
| Taxonomy Classification: | Contractor |
| Taxonomy Specialization: | Home Modifications |
| Taxonomy Definition: | |