Healthcare Provider Details

I. General information

NPI: 1427565522
Provider Name (Legal Business Name): KEYSTONE COMMUNITY LIVING, INC.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/10/2018
Last Update Date: 01/10/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

72 GRAMERCY GDNS
MIDDLESEX NJ
08846-1687
US

IV. Provider business mailing address

154 FRONT ST
SOUTH PLAINFIELD NJ
07080-3402
US

V. Phone/Fax

Practice location:
  • Phone: 908-757-1080
  • Fax:
Mailing address:
  • Phone: 908-757-1080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code320900000X
TaxonomyIntellectual and/or Developmental Disabilities Community Based Residential Treatment Facility
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name: RAY FANTUZZI
Title or Position: PRESIDENT
Credential:
Phone: 908-757-1080