Healthcare Provider Details

I. General information

NPI: 1457528085
Provider Name (Legal Business Name): NORTHEAST INDEPENDENT LIVING SERVICES
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 05/13/2008
Last Update Date: 03/08/2023
Certification Date: 03/08/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4500 PARIS GRAVEL RD
HANNIBAL MO
63401-5422
US

IV. Provider business mailing address

4500 PARIS GRAVEL RD
HANNIBAL MO
63401-5422
US

V. Phone/Fax

Practice location:
  • Phone: 573-221-8282
  • Fax: 573-221-9445
Mailing address:
  • Phone: 573-221-8282
  • Fax: 573-221-9445

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code251J00000X
TaxonomyNursing Care Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code251X00000X
TaxonomySupports Brokerage Agency
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State
# 4
Primary TaxonomyN
Taxonomy Code372500000X
TaxonomyChore Provider
License Number
License Number State
# 5
Primary TaxonomyN
Taxonomy Code385H00000X
TaxonomyRespite Care
License Number
License Number State
# 6
Primary TaxonomyY
Taxonomy Code376J00000X
TaxonomyHomemaker
License Number
License Number State

VIII. Authorized Official

Name: TARA FORTNER
Title or Position: FINANCE DIRECTOR
Credential:
Phone: 573-221-8282