Healthcare Provider Details

I. General information

NPI: 1093991234
Provider Name (Legal Business Name): INDEPENDENT LIVING GROUP HOME, LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/17/2008
Last Update Date: 11/18/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

924 CLOISTER DR
WINSTON SALEM NC
27127
US

IV. Provider business mailing address

7748 N POINT BLVD
WINSTON SALEM NC
27106-3310
US

V. Phone/Fax

Practice location:
  • Phone: 336-767-4540
  • Fax: 336-283-9288
Mailing address:
  • Phone: 336-767-4540
  • Fax: 336-499-0651

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code251S00000X
TaxonomyCommunity/Behavioral Health Agency
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code311ZA0620X
TaxonomyAdult Care Home Facility
License Number
License Number State
# 3
Primary TaxonomyN
Taxonomy Code320600000X
TaxonomyIntellectual and/or Developmental Disabilities Residential Treatment Facility
License Number034-224
License Number StateNC
# 4
Primary TaxonomyN
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VIII. Authorized Official

Name: SHANITA LOVELACE
Title or Position: DIRECTOR/ OWNER
Credential: RN
Phone: 336-767-4540